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32C-126 (6) v '!7 �• o M D 3 ZZ m r V ao n "t N Z ` o v € z o -• o ..l � 6r •..tr 0 r— a 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, ........ 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