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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. `� _ 1 Cl Alterations
NORTHAMPTON, MASS. " 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
a t/
Garage
1. Location �e) C(/ I LL `[-qA-vV� TO Lot No.
2. Owner's name TG ft`t\l Address_
3. Builder's name Address
Mass. Construction Supervisor's License No. Expiration Date
4. Addition / C)
5. Alteration /Uf,(;i,r W l'ki CW S , O /07 Sc r C)6C
1-4-cy oc k r- ler -+'�"fs
6. New Porch ao
7. Is existing building to be demolished? Alt)
8. Repair after the fire /VO
9. Garage pq o C, '�fK S No.of cars Z Size 9;�-C-t c
I0. Method of healing /-/�0 7��� C L � 1�G G��Gr )-z ✓r
GC
11. Distance to lot lines S b try�Iasi�ys
12. Type of roof n S e 1qc1 Lf" h o C--tA 5
13. Siding house L L 0,1�,Ii u 0,1 — 0 C 11 e,
14. Estimated cost:- j CZ7
The undersigned certifies that the above statements are true to the best of his, her
knowledge and ief.
/1"'L,oz Az�
gnature o responsible app can!
Remarks
limp
°�`� 1 JUN 41997 Crzt of Nart4amptun
� B • �lxssachtrsctis
DEPARTMENT OF BUILDING INSPECTIONS ~
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee)
with a principal place of business/residence at:
_; (A,• t_L 0-v"'S /0 c t1Z T H ,+-M taTC M (phone#)
(street/city/statrhip)
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:
(lamrance Company) (Policy Number) (Expiration Daze)
j 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 Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shoot ifnoarasry to include information pextaiaing to all ooahnctors)
( ) 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 vibile homeowners who employ priors to do maintm cmstudion or repair work on a dwelling of
not more than thane vuita in which the homeowner resides or on the grounds appurtenant therdo art not gwerally considered to be
employers under the woricees oompeasstim Act(GL152,ss 1(5)),application by a homeow=for a license or permit may evidence the
legal oahrs ofan employer under the Worlcoe's Compemation Art.
I understand that a copy of this rtatemect maybe forwarded to the Deparuncoi of Indmrial Aeadea&office of luvJ anoe for the
coverage verification and that failure to sexttro coverngo under section 25A of MGL 152 can lead to the imposition of criminal penalties
comistiag of a f ne of up to$1,500.00 anNor impruoument of up to one year and civil pemattia is the form of a Stop Work order and a
fins of 5104.00 a day against ma. 4
Signed this nay of Jv r`L 199 7 For d um
Permit Number
g - _ l� �t
Si 6fLi o ermittee
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 coltma to be filled in
by the Building Department
Required
Existing . Proposed By Zoning
Lot size
Frontage
Setbacks - front
- 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:
(volume -& location)
13 . Certification: I hereby certify that the informatior{,contained herein
.1
is true and accurate to the best of my knowled e.
DATE: V�/ 3 APPLICANT's SIGNATURE
NOTE: Issuanoe of a zoning Permit does not relieve an a plioanYs but-den to comply witt),,rpll
zoning requirements and obtain all required permits fro the Board of Health, Conservation
Commission, Department of Publio Works and other appliomble permit granting authorities.
FILE #
_ 1 #
F , C!. `
JUN d 1997
DIE
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: n
Address: mil`l l t G, vvt S s r- Al o f-1')1c,tr VV j Telephone:
2. Owner of Property: f7ci yy,-P,
Address: .SC,W-e- Telephone: SS ys�
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# `�- Parcel# District(s): ` C-1
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property b li
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
C A)< � /00v I,Vql
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-X- 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)
C) r(/
FILE if -7
J, .PP8%W1iT/CONTACT PERSON:
ADDRESS/PHONE:
f
PROPERTY LOCATION:
MAP PARCEL: 12 C12 ZONE_ j&��
THIS SECTION FOR-OFFICINI, USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCL SED REQUIRED DATE
ZONINC-FORM M,IFD OUT
Ff-P Paid
Rivilding Permit MUM Put
Fe
�-
THE ,LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION
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
1,6 lf,-7
Signature of Building for ate
NOTE:Issuance of a zoning permit does not relieve an appiioant's burden to comply with ail
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioable permit granting authorities.
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