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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. �� ^ �7 Alterations
NORTHAMPTON, MASS. �� �G l5 } 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location F `� Lot No.
2. Owner's name �a3:5c �' ��i Address
3. Builder's name <;Z�>Z t V k Address .�
pe L C L( Expiration Date
Mass.Construction Supervisor's License No. � o-
4. Addition
5. Alteration cam.e%0 6L V,
6. New Porch
7. Is existing building to be demolished? 1`1
8. Repair after the fire 'V o
9. Garage --11 zo No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost:-
1�U, 01:_1 The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief. —
�C
Signature of responsible app icant
Remarks
04�t1AJdpTO
rzfLI of 'Ttrzf4aiitpfoil
3 �� � � f�assxcflusrtfa
.:�PARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKEWS COMPENSATION INSURANCE AFFIDAVIT
(licen_See/permi tt ee}
with a principal place of business/residence at:
S t-Wy, c (phone#) ( `�
(strrt:t/ci ty/Saatchi p)
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:
uy 97 fy
(Insurrance Company) (Policy Number) (Expirarion 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 Numbcr) (Expiration Date)
(Name of Contractor) Unsumcc Compar y/Policy Number) (Expiration Date)
(Name of Contractor) (Insuran(-- Company/Pokcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addi6oaal sheet if necc to include information pertnimng to ell ooh ndon)
( ) 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 asratti that viWio homeowners woo anploy pasons to do m&bA a=t wart c on or repair work on a dwelling of
nut mom than tbroe units is which the homeowner resides or on the grvuads appurtenant ibxato ace out gto=ily coasidcred to be
employaa under tba worker's oompcasatioa Act(GL152,ss 1(5)),application by a homeowner for a Gcrase cc permii may evidcaoe the
legal ctatru of an employee under the Works x Compensation Act
I underataad that a copy of this rtatcmeat may ba forwarded to rho Department of Industrial Aocidmii OfEw of Inausnoe for dw
coverage verification and that fail=to aaure covcntgo umdcr suction 25A of MOL 152 can lead to tbd iu o-of criminal peaal6cs
coaiLemg of a-fine of up to S1,500.00 and/or imprisoumcnt of tip to ow year and civil penalties is the form of a Stop Wok Ord-and a
find of 5100.00 a day apa inst mc.
Signed this 2_Y I '. day of 1997 For&TUtmetal tm only
Permit Number
Map# Lot#
Signaturt of LicroseeNcrMittee
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 MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This coluam to be filled in
by the Building Deynztaant
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
&paged parking)
# of -Parking Spaces
# of Loading Docks
Fill:
4 vol ume-& location)
13 . Certification: I hereby certify that the information contained herein
(,I is true and accurate to the best of my knowledge.
DATE: - APPLICANT's SIGNATURE
NOTE: lasuanoe of a zoning permit does not relieve an applioants burden to oomply With 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 #
. �
� \
NN Z 4 1991
w File @o'
�� ���� �� �� �
=~=~I== P== M=-� �= P=====IO�" « �r�= ^ ��
PLEASE TYPE OR P=T ALL INFORMATION
1. Name ofApplicant:
-
Address ^���� c�q4� Telephone: r�
2� Owner of Property:
Address: 16 Telephone:
3. Status ofApplicant: _�� Dwnor -Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map District(s):
(TO BE FILLED (NBY THE BUILDING OEPART/NENT)
5 Existing Use ofStructure/Property ~!» Pr*1 ka'j:�«
S. Descdption of Proposed UseMork/Project/Occupation: (Use additional sheets if necessary):
7 Attached Plans: Sketch Plan Site Plan Enginaored/8un/eyedP|anu
Answers to the following 2 questions may be obtained by checking vAth the Building Dept or Planning Department Files.
0 Has a Special Per ding ever been issued for/on the site?
NO DON'T KNOW YE /F YES,date issued:
IF YES: Was the permit recorded ot the Registry ofDeeds?
NO DON'T KNOW X YE
IF YES: enter Book Page _ end/or Document
D. Does the site contain o brook, body of water orwetlands? NO `>'� DON'T KNOW `/E
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobe obtained Obtained .date issued:
(FORM CONTINUES QN OTHER SIDE)
1 4
FILE #
2 41997
APPLICANT/CON ACT PERSON: �C/3�3
.� Ot
PROPERTY LOCATION: e
MAP C'- PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FH,T,F,D OITT
Fee pnid
llnildin2 Permit Filled mit
Fee Pqifi T?
Tyne of Constnirtinn-
Accessory Structurt-
c/
THE LLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
6 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
Septic Approval-Bd of Health Well Water Potability-Bd Health
Permit from Conservatio ommission
Signature of Building r Date
NOTE:Issuanoe of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioable permit granting authoritles.
i0'd _11J101
PROJECT; Lr'C..e rr.�� �l"'L, ........
RYAN S. HELLWIG, PE 3[e rk g rr S".
STRUCTURAL ENGINEER
28 Aldrich Street l f� � �
Northampton,MA O1060 h•�
Voi=: 413-584-HLWC,(4594)
PAM,:
Pax: 413-584-HUXTax(4593)
JogNO.: _........... .......- --------
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