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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel o. Alterations
NORTHAMPTON, MASS. 19 r" Additions
' APPLICA ION FOR PERMIT TO ALTER Repair
/ Garage
1. Location h a T Lot No.
2. Owner's name ,-C Address —G o,� T a
3. Builder's name e0-0rH sic'JUC-U /boo C Address 6 3 7 ��` f_.
Mass.Construction Supervisor's License No 0 3 Expiration Date
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 �u/�"au W /?0 o l� Sly,, ,,, C
13. Siding house 5—t nc, „n �6 BA"ar
14. Estimated cost
173). 0U
The undersigned certifies that the above statements are we to the best of his, her
knowledge an lief.
Signature of responsible app ican!
Remarks
9 � j�blxssacllnrrctts
IEPT Gr z "`' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
,F
(IlcenSwipermittee)
with a principal place of business/residence at:
s �e (phone#) �T*C ��2
(st1-eet/city/st ap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Ex#mtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addition!short ifnoD=mjLry to inchrdo information pertaining to all ooa radora)
( Irani 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 while homeowners who employ pc=m to do mamte=tce,oxrgr ction or repair work on a dwelling of
not more than throe units is which the homeowner resides or on the groins appurtenaat thereto are not gcocrally 000ndered to be
employers under the-uke's co-pen:u4ca Act(GL152,ss 1(5)),application by a homeowner for a license or pcfmd may evidence the
legal status of an employer under the Workees C.ompamation Act
I undesuatamd that a copy of this statement may be forwarded to the Depwtrtx 2 of Industrial A=dw&OfSoo of In9u vmm for the
coverage verification and that failure to&==coverage under section 25A of MGL 152 can lead to the inl;md oa of aiminal penalties
oomisiin of a fine of up to$1,500.00 and/or of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against mc.
For deputmedsl use Only
L, Permit Number
�� Map# _Lot#
SiVmbire of Licensee-no then e
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 cola= to be fiZLed 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 parking)
# of -Parking Spaces
f of Loading Docks
Fill:
4 volume-& location)
13 . Certification: I hereby certify that the information containe herein
G is true an accurate to the best of my knowledge.
DATE: APPLICANT's SIGNATURE r
NOTE: las an a of a zoning permit does not relieve an appiloant's burden to oomply With 4111
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commisslon. Department of Publio Works and other applloable permit granting authorities.
FILE if
APR 6XIM
File No.
Pt
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applican . a T r o f
Address: e 3 4 — Telephone: 5 kC- 2
2. Owner of Property:
Address: r r Telephone:
3. Status of Applicant: Owner L--contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s): ti--
(TO BE FILLED IN BY THE BUILDING DEPARTMENT' Q�
5. Existing Use of Structure/Property HouS 3
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 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)
( L �5 (1
°�•. a FILE # J C' .� C> 03L)
APPLICANT/CONTACT PERSON: z
)EPI T r ADDRESS/PHONE: e
PROPERTY LOCATION:
MAP �'� PARCEL: ZONE
THIS SECTION FOR.OFFICIAL USE ONLY:
PERMUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM Fn.T.FD OUT
Fee Pnid
T OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATIOM
Approved as presented/based 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
Ei.":;Approval-Bd of Health Well Water Potability-Bd Health
:.
Permit from Conservation C mmission */5
/.__._ .
Signature o u o .,.'y
to
NOTE: 1sau. of a zoning permit does not relieve an applloant's burden to oompty with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commisalon, Department of Pubiio Worka and other applioabie permit granting authorities.
City of Northampton REQUIRED INSPECONS
TI
} ' 1. Footings and Walls
N
BUILDING DEPARTMENT 2. Structural Components in Place
3. Complete Building*
No.
1436 Office of the Building Inspector
Zoning Form No. 963380 Date 4/7/98 Fe($20.00 Check# 2018
Page, 25C parcel 163 ,Zone URB Section 127 ❑ Yes ® No
BU]IL"ING PERTVHT
a
* Plumbing and Electrical Inspections required
THIS CERTIFIES THAT Western Mass Siding & Roofing before Building Inspections
has permission to strip & shingle garage roof & siding on dormer Inspection on Site—Foundations
situated on 140rchard St – Richard carnall Inspection of Plumbing—Rough
provided that the person accepting this pem7 t shall in every respect Inspection of Plumbing—Finish
conform to the terms of the application on file in this office, and to the Gas Inspection
provisions of the Statutes and the Ordinances relating to the Construction, Inspection of Wiring—Rough
Maintenance and Inspection of Buildings in the City of Northampton.
Any violation of any of the terms above noted is an inunediate revocation Inspection of Wiring—Finish
of this pen-nit.Expires six months from date of issuance,if not started. Building Inspection—Rough
Note:A certificate of occupancy will be issued by this office upon return Insulation Inspection
of this card signed by the Plumbing,Wiring and Building Inspectors.
Building Inspection—Finish
** Install per Manufacturer's information: windows, vinyl siding,roofs
Smoke Detectors(Fire Department)
and woodstoves
Other
THIS CARD MUST BE DISPLAYED IN A CONSPICUOUS P LACE ON T PRE ISES
Ce.-6ficate of Occupancy
Building Inspector
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C lt of Northampton REQUIRED INSPECTIONS
' 1. Footings and Walls
BUILDING DEPARTMENT
� 2. Structural Components in Place*
3. Complete Building*
No.
1436 Office of the Building Inspector
Zoning Form No. 963380 Date 4/7/98 F420.00 Check# 2018
Page, 25C Parcel 163 ,Zone URB
Section 127 ❑ Yes No
BUILDING
* Plwnbing and Electrical Inspections required
THIS CERTIFIES THAT Western Mass Siding & Roofing before Building Inspections
has permission to strip & shingle garage roof & siding on dormer Inspection on Site—Foundations
situated on 140rchard St - Richard Carnall Inspection of Plumbing—Rough
provided that the person accepting this permit shall in every respect Inspection of Plumbing—Finis;,,
conform to the terms of the application on file in this office, and to the Gas Inspeon
provisions of the Statutes and the Ordinances relating to the Construction, Inspection of Wiring—Rough
Maintenance and Inspection of Buildings in the City of Northampton.
Any violation of any of the terms above noted is an immediate revocation Inspection of Wiring—Finish
of this permit.Expires six months from date of issuance,if not started. Building Inspection—Rough
Note:A certificate of occupancy will be issued by this office upon return Insulation Inspection
of this card signed by the Plumbing,Wiring and Building Inspectors.
Building Inspection—Finish
** Install per Manufacturer's information: windows,vinyl siding,roofs
and woodstoves Smoke Detectors(Fire Department)
Other
THIS CARD MUST BE L+ISPLA D W A CONSPICUOUS P WE ON PREMISES
Certificate of Occupancy
Building Inspector