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25C-005 (5) - a > 2 < y v v o• r � � m � D 3 zm Z �• -� � � C m Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations c' NORTHAMPTON, MASS. �.3 19 1� Additions % ' APPLIa CATION FOR PERMIT TO ALTER Repair Garage 1. Location ' T © t ✓ Lot No. 2. Owner's name FJO e— K rl Address / /-)v,,-4 Sr /��•'r G•« ,/`c>�a 3. Builder's names• e-57%grki s L ,q gc'ef Address t< r ER; T % C, Mass.Construction Supervisor's License No. C? 3 Y 6 y Expiration Date ! f 4Z 4. Addition 5. Alteration 6. New Porch 7. Is existing building to be demolished? 8. Repair after the fire 9. Garage No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof 13. Siding house n rj c' < V7 J&fiL 3 •3� 14. Estimated cost:- Ic The undersigned certifies that the above statements are we to the best of his, her knowledge ,Ffe ef. Signature of responsible app,icant Remarks I 1 1W"'X ago w � 6 �l,tssxrhnsctla m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ORDER'S COMPENSATION INSURANCE AF'F'IDAVIT (licen�Pemiittee) with a principal place of business/residence at: 3(fnL-- o� �. (phone#) C' st=ucitylstazrJap) do hereby certify, under the pains and penalties of peg3ury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insuuance Company) (Policy Number) (Expiration Daze) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Cornpany/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Nmnber) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach a&htioml sheet ifnccessary to iochufe information prsiaining to all ooutractorn) (P,Y""I�am a sole proprietor and have no one working for me. ( } I am a home owner performing all the work myself. NOTE:please be aware that whilo hon=wncrz who employ persons to do mamas•nan t constuctioo or repair work on a dwelling of not more than throe units is which the homeowner sides or oa the grounds appurtenant therctn are not geaunity ooasi lercd to be empioyen under the worker's oompcnsatioa Act(GL152,"1(5)},application by a homeowner for a licmx or pan H may evidence the legal m-tua of an employer under the Workeez Compomation AcL I undastaad that a copy of this statcmrni may bo forwarded to the DcpartmmQ of Indauiri al Amd--&Offioo of Irznuanco for the covaage verification and that failure to secure coverage under si=on 25A of MGL 152 can lead to tba imposition of criminal pcnal - comisLiag of a fine of up to S1,500.00 and/or unprisonma2 of up to one year and civil penalties in the form of a Stop Work Order and a fine of S 100.00 a day&&I:U st inn. Signed ____day f 1997 For departmastal use only Permit Number t m Niap# Lot# SignarL 10. Do any signs exist on the property/? YES NO IF YES,describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO IF YES,describe size,type and location: 11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This corm to be filled in by the Building Department Required Existing Proposed By Zoning Lot size Frontage Setbacks - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg ' &paved parki.ng) # of -Parking Spaces # 'of Loading Docks Fill: vol-ume--& location) 13 . Certification: I hereby certify that the information contai-ped herein is true and accurate to the best of my know DATE: APPLICANT's SIGNATURE NOTE: Issua a e o a zoning permit does not relieve an applioanre bu en to oomply with,,ill zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works and other applioable permit granting authorities. FILE # 2 3 t Fi 1 e No. / j� ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: c i � �� e f �-r Address: 3 Sf �' "/6a , Telephone: 2. Owner of Property: �f&;,I -C' -4� Address: /,,Z$ d),or-A 57 Telephone: 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): 4. Job Location: I a s j Parcel Id: Zoning Map# �— Parcel# ,� District(s):_ BE FILLED IN BY THE BUILDING DEPARTMENT 5. Existing Use of Structure/Property =, 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files. 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW -- r.. YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or�Document# 9. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES,has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ,date issued: (FORM CONTINUES ON OTHER SIDE) FILE # Q 6 2 8 1 "Qlq P ?APj?PLC'ANT/CONTACT PER N: ' ��- /�C� J F,XC Zdh ,V . 1A. ° o? ADDRESS/PHONE: PROPERTY LOCATION: MAP PARCEL: ZONE THIS SECTION FOR-OFFICIAL USE ONLY: PERIVIIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM M.I.ED OUT Fee Pnid Addition to Existing L� THE LLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION: Approved as presentedfbased on information presented Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb,.Cut from DPW Water Availability Sewer Availability e Septic Approval-Bd of Health Well Water Potability-Bd Health Permit from Conserva ' Commis ' n 0 Signature of Buildin 09Fe for 6ate NOTE:issuance of a zoning permit does not relieve an applicant's burden to oompty with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works and other applicable permit granting authoritles. 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