36-011 (5) ,9 '> 2
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Zoning
77' 3-'
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. ;°z Alterations
NORTHAMPTON, MASS. ��' 19W Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location U Lot N
2. Owners name 41)4-Address
3. Builders name 71 Address --
!.i
Mass.Construction Supervisor's License No. (.) 6 Expiration Date 4 C I
4. Addition
S. Alteration
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:- �
The undersigned that the abov state is are true to the best of his, her
knowledge b
Signature of responsible app,icant
Remarks , C2'w�
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Mass ach not its
m DEPARTMENT OF BUII.DrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVTr
(li�nsec/pemuttee}
with a principal place of business/residence at:
°�� : (phone#)
10 (Stre'--Ucity/sta e 2 p)
do hereby cerwy`, under the pains and penalties of pequ-ry, that-.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Compa-ay) (Policy Number) (Expiration Date)
a sole proprietor, general contractor or homeowner(circle one) and have hired
>��elzutractors 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: CompallyiPoliry Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiceul sheet ifneocssuy to include iaforrnarion pertaiuing to all occrtradora)
( ) I am a sole proprietor and have no one working for me.
( ) Y am a home owner performing all the work myself.
NOTE:please be aware that while hcmeownm who cruploy pcciom to do maintenance,coastrvciioa or repair work on a dwelling of
aot mote than throe units in whvch the homeowner rciidcs or on the vviads g7artta thereto are not gerxtally comidered to be
eutployers under the wotiet Omq>cnsation Act(GL152,"1(5)),application by a homeownix for a tiers=or permit may evidenoe the
legal ctahra of an employer under the Worker's Congxasation Act
I understand that a oopy of thin statement may be forAmrdod to the Dcpertmcat of Industrial Ao idc>zb'Oflioo of Terrors nee For tba
coverage verification sad that fauure to scutre covcrago under sccton 25A of b(GL 152 can lead to the imposition of criminsl p=ltics
cornisciag of a fine of up to S 1,500.0o nrtd/ot�prisomix A of up to one}car and civil pcnaltics in the form of a Stop Work Order and a
fine of 5100.00 a day agairbst me.
Signe this d of� � 199Y For degutmcdaltt,eonly
Permit Number
2` maP4 Lot#
Si tare of Li cruuttee
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
LACE' OF INFORMATION.
This col— to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks °Aircant..._..
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paged parkin'g1
# gf Parking spaces
f of Loading Docks
Fill:
volume --& location)
13 . Certification: I hereby certify that the information co wined herein
is true and accurate to the best of my kno
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.UA1' ,'" APPLWANT's SIGNATU
NOTE: anoe a stoning permit does not relieve an as liomnvs burden to oomply With 4m
xoninfj r"ulrementa and obtain all required permits IF m the Board of Health, Conservation
Comingualon, Department of Publio Works and other applicable permit granting authorities.
FILE #
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APR 1 6 1998
a File No. �
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: C r� �e elephone:�
2. Owner of Property:
Address Welephone:
oG7o
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: /Q,F��S� � �� �- U/U(Q
Parcel Id: Zoning Map#36 Parcel# District(s): `IV��-
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
a
7. Attached Plans: Sketch Plan Site Plan Engineered/ eyed 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)
�``�?�I ,.,'. FILE # Ct' 9
4 � 3 f
;I'S APR 1 6 1996
APPLICANT/CONTACT PERS
x ADDRESS/PHONE: �&T
PROPERTY LOCATION:
MAP � PARCEL:
THIS SECTION FMOFFICIAL USE ONLY:
PERNUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM MLED OUT
Pet- PAid
1Rni1din2 Permit Filled nut
Addition tnF-rigting
Tnchided-
✓'
G,
THE LLOWING 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
it fr Conserva ' ommissigp
i
Signature of Building ector Data/
NOTE:Issuance of a zoning permit does not relieve an applioant's burden to comply with ali
_ zoning requirements and obtain all required permits from the Board of Heaith, Conservation
Commission, Department of Public Works and other applicable permit granting authorities.
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