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32C-243 (5)
i > i T � t > D r Z r'7 r� C Z _ r _ > rn A Zoning Miscellaneous Additions,Repairs,Alterations,etc. // Tel.No. Alterations - 1 11 NORTHAMPTON, MASS. 197 Additions ' APPLICATION FOR PERMIT TO ALTER Repair Garage 1. Location '111-11 c Lot No. 2. Owner's nae A dress f 3. Builder's name fj - Address / ` xi', Mass.Construction Supervisor's License No. L Z'/5�A 4 4L Expiration Date l C 4. Addition 5. Alteration 6. New Porch 7. Is existing building to be demolished? Al 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:- The undersigned certifies that the above statements are true to the best of his, her knowledge and belief. r i� aturt j responsible appucanc Remarks r L> G 0 a ., cJ /) W J tIzzeu '7 iU19G S L iv, j °�• �(11AAf P�, O O (rxo of 'Narf4alliptor z 3 B �asaschnsrtta � J�EPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION MSURANCE AF'F'IDAVIT �r. 7—t. OL �4: (licenserJpermiltee} with a principal place of busiinness/resideennce at: �'�7 u l/1 V0 . (phone#) JrkS 1612-17 (streeUcity/stn zip) 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: (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) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml short if necc=Lry to inchsdo informstioa pertaining to all oo.trncion) (-,�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 whim homeowners wbo employ p=a=to do mxi*•tca cc,consuuctioa or repair work on i&MIling of not more than three uatU in which the homeowwocr resides or on the groin apptutenaat tb=W are not generaky coandered to be employers under tbo worker's oompcnsatioa Act(GL152,rs 1(5))�application by a homeowner for a license or Pan"d maY evidcmce the legs!clatiu of am employer under the Workeet C,ompemation Act I unders�trot a copy of this sulcrocm may be fw vvxrdod to the Depert[3 o of lnutrid ADcid,=&Of oe of Imursnoe for the coverage verification and that failure to Sartre coverage under section 25A of MGL 152 can lead to tho imQosihon of criminal penalties oomisiiag of a fine of up to S1,500-00 and/or imprisonn>cn of tip W ooe year end civil pmattia in the form of a Step Work order and a fins of 5100.00 a day against me. Signed this _day of / Z— 1991 For a nae only Permit Number Map# Lot# — si of i ermittce t 10. Do any signs exist on the property? YES NO_J,� IF YES,describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES _ NO y 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 filled in by the Building Dcpartment Required Existing Proposed By Zoning Lot size Frontage Setbacks - frnnt - side L: R: L: R: - rear - Building height Bldg Square footage %Open Space: (Lot area minus bldg &paved parking) # of -Parking Spaces # of Loading Docks Fill: -(volume--& location) 13 . Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: /'1P1 APPLICANT's SIGNATURE NOTE: 1 ant of a zoning permit does not relieve an a lioanrs burden to comply With all zoning ulre ents and obtain all required permits from the Board of Health, Conservtstion Commission, Department of Publio Works and other applioable permit granting authorities. FILE I File No. � ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: 7 Address: NZ UI/lz—Telephone: 2. Owner of Property: Address: `J Cf ©rli7_ Telephone: ZU 3. Status of Applicant: Owner r/ Contract Purchaser Lessee Other(explain): 4. Job Location: _ Z 11-11_ 9z Parcel Id: Zoning Map#—j—a7A2- Parcel# District(s): (TO BE FILLED IN BY T HE BUILDING DEPARTMENT) 5, Existing Use of Structure/Property ,az 6. Description of Proposed UseNVork/Project/Occupation: (Use additional sheets if necessary): V Itli4raj 6t)11L1j1ja.2 1� llr4d ':Qr .//zp/l 4GJv 'r�� / Gl) llu�a Ix //DaU � S!1 X/1G1G �/�tJ Ji�rft S � M(/� 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. S_ 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 f/�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 # O U `l 0APPLMT/CONTACT PERSON: ADDRESS/PHONE: PROPERTY LOCATION: �lQ �( .oe� MAP c PARCEL: J�3v ZONE S THIS SECTION FOR-OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FHLET) 011T Fee Plid Fee PAid A(Mitinn to Existing /� / -v✓ �[ i' Arressncy Structure / V �� .FOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION- 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 ermit from Conservatio ommission Signa r - Date NOTE:Issuanoa a zoning permit does not relieve an applloant's burden to comply with all zoning requirements and obtain ail required permits from the Board of Health, Conservation Commission, Department of Public Works and other applicable permit granting authorities. t ro N �•w•i. 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