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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 1910 Additions
APPLICATION FOR PERMIT TO ALTER
a Repair
.�.
Garage
1. Location _ �r Lot No.
2. Ownee s name 1 e I Gt �•. /I ,, ,, Address
3. Builder's name O, Vtv (/J Address S `^
Mass.Construction Supervisor's License No. 141S Expiration Date
4. Addition
5. Alteration R, � C i W� c Ul c (te-`y`-zT
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
14. Estimated cost-
&L
The undersigned certifies that th4abwove tatements are we to the best of his, her
knowledge and bell f 'Signatuonsible app icant
Remarks
�TttAMP�.
t'O Oy
e Crz of 'Nart4aillpton
�l:ssachtttcctla
t;
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
'Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Cla Sr-)
with a principal place of business/residence at:
(phone#) 7� 7'
(street/ci ty/slate/a P)
do hereby certify, under the pains and penalties of perjury, that:
} I am an employer providing the following workers compensation coverage for my
employees working on this job.
83H C13°0� K?b-59,C17 R113k
(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) (lnsurancc Compmy/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anad,additioml sleet ifnooesaary to include information pertaining to all cocaradon)
( ) 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 while homcowneta who employ p==to do maintenance,construction or repair work on a dwelling of
not mot o than throe units is which the homeowner resides or oa tho groin appartenarrt therdo are not generally ooaride ed to be
emPloYua undo the wOrka's compcnsation Act(01,152,m 1(5))�,application by a homcowna for a license oc permit may evidence the
legal status of as employer under the Wockeeg compemation Act
I understand that a copy of this s tcmmt may be forwarded to tbo Departmrn2 of Iodautrial Accidw&Of5oo of Insu-00e for the
coverage verification and that failure to aortae coverage under section 25A of MOL 152 can Iced to the imposition of criminal penalties
ooasL6ng of a fioc of up to S1,300.00 and/or impsis of up to one year and civil penalties in the form of a Stop W orlt Order and a
&to of 5100.00 a day against mc.
For departmental use only
�L►7/,j��� � � � Permit Number
Mao _Lot#
:;X Sigma(=of Licensee/Pe ttee
t ti
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 colnmm to be filled in
by the Building LDepart ,e t:
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
ht of Loading Docks
Fill:
Avolume -& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: ✓ S APPLICANT's SIGNATURE ;��z
NOTE. Issuanoe of a zoning permit does not relieve an appliomnt's burde o oompty wit" 4111
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 #
4 6 1 File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: ( t�' � A/- d /,/-4-'e,-<'-
Address: 9Y IUD t Telephone: 01165? 7
2. Owner of Property: 916-Laz Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
�c Other(explain):
4. Job Location:
Parcel ld: Zoning Map# Parcel# C,-29c�- District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)—
5. Existing Use of Structure/Property
�Q3 l�l'L,c e
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
O n`?— 0 ) �2 f1 IctC�h1 c��r JijtA ,.L
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)
a E o FILE # 9630
(j 0
Ap &CMONTA.CT PERSON:
ADDRESS/PHONE:
PROPERTY LOCATION: �-
MAP / PARCEL: NE,�i.
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKI..IST
ENCLOSED REQUIRED DATE
ZONING FORM FH,T,FD OUT
Fee Pnid
Fee Pnid
Rernndelin2 Interior 1 )
-� '
T OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATIW
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
�roval-Bd of Health Well Water Potability-Bd Health
Permit from_CCoo�n'servat' Commission
Signature of Buildin ector Date
NOTE:Issuance of a zoning permit does not relieve an appiioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commisslon, Department of Publio Works and other applionble permit granting authoritles.
�w
City of Northampton REQUIRED INSPECTIONS
I. Footings and. BUILDING DEPARTMENT 2. Structural Components in Place*
P
3. Complete Building*
No. 1344 Office of the Building Inspector
Zoning Form No. 963280 Date 3/11/98 Fee $20.00 Cbeck# 3144
Page, 17A Parcel 242 ,Zone URB Section 127 ❑ Yes D No
BUI]LDING PERIN/HT
* Plumbing and Electrical Inspections required
THIS CERTIFIES THAT Walter Marek & Son before Building Inspections
has permission to install replacement window Inspection on Site—Foundations
situated on 72 Lake St - Peggy Miazga Inspection of Plumbing—Rough
provided that the person accepting this pen-nit 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 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 Smoke Detectors(Fire Department)
and woodstoves
Other
THIS CARD MUST BE DISPLAYED IN A CONSPICUOUS PLACE ON T PREMISES
Certificate of Occupancy
Building Inspector