36-179 (3) ' o
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. e— 4 19 7 Additions
a APPLICATION FOR PERMIT TO ALTER Repair
Garage
L Location �=S��/�C✓lV J�fi 5r t 1- Lot No.
2. Owner's name C�-1- �k r�'�c_ r14X-°S r-, Address .
3. Builder's name !_ � o P--., r .S qtr Address �� ®/1J70 C_l- �f
Mass.Construction Supervisor's License No. /a 1601Ga0 Expiration Date zzyp
OF
4. Addition �1,�,, f
5. Alteration �' x�r �r-� J:�S SN 44 ��--
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-
/�400
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
ignature of responsible app icant
Remarks
� � �lassachnt:ctta
pip?pF$UQpING iN$PEC(i(lD1�P4TMENT OF BUILDrNG INSPECTIONS
NORTNA�r MA C+1GS4 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenseeJpermittee}
with a principal place of business/residence at:
4 aCIC (Phone#)
(sttcei/city1=d2iP)
do hereby certify, under the pains and penalties of pe*i y, that:
( ) I am an employer providing the following worker's 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/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet ifnecena:y to MCKWe information pertakmg to all tract.ors)
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 while homeowners who employ p=om to do mtamieaaace,suction or repair work on a dwelling of
not more than throe units in which the homeowner resided or ou the grounds appurtenant thereto art not generally coandemd to be
employera under the worker's con4x=aticn Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal status of as employer under the Worker's Compensation Act
I understand that a copy of this sfatemad may be faswaniod to the Dcpartmeaa of Dial Ac6&n&Office of Inwrwx a for the
coverage verification and that failure to secure cow-W under section.25A of MGL 152 can lead to the imposition of criminal penalties
oomiging of a fine of up to S1,500.00 and/or imprisoameut of up to one year and civil pe naWes in the form of a Stop Work order and a
fins of 5100.00 a day against tne.
Sign this / day of 199 7 For depatmAntal use only
V, Permit Number
Map# Lot#
Signahrre of ermittee
f 1
10. Do any signs exist on the property? YES
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 DOE TO
LACK OF INFORMATION.
This column 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
' &paged parking)
# _pf Parking Spaces
# of Loading Docks
Fill:
vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
_1
DAVE: d/W//Q ;7 APPLICANT's SIGNATURE
NOTE: lssuanoe of a zoning permit does not relieve applioant' burden to oonnply witip,..42ll
zoning requirements and obtain all required perms from the Board of Health. Conservation
Commission, Department of Publio Works and other appiiooble permit granting authorities.:;..
FILE #
9 FO
.D Of BUILDING INSPECTIONS
File No.
NOR ` S,'
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: r , A, jjvt d C_ iC- _S C Telephone: A l 'S'�_Qea '7
2. Owner of Property: S lz�
Address: �S 1�c.-r�t�l�� � ®I' Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): A
4. Job Location: �v�-l��`�
Parcel# / District(s):
Parcel Id: Zoning Map#
(TO BE FILLED IN BY THE/BUILDING DEPARTME�M
5. Existing Use of Structure/Property --K 0
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
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 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)
• { a U `i FILE if
Y L5 u 3�
�9199�
AP LICANT/CONTACT PERSON: Art,& jA _sg6 rT
VM Of BU"PROPERTY LOCATION:
MAp _ PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERNIIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING I ED OUT
Fee Pn*d
Hiii1ding Permit Filled nut
Cp — ✓-
0'�ner/Dcruvant ',Stnternent ,,
�.
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
Permit-from Conserva ' Com i n
Signature of Building ector Date
NOTE:Issuanoe of a zoning permit does not relieve an appltoant's burden to oompty with all
_ zoning requirembnts and obtain ail required permits from the Board of Health. Conservation
Commisslon, Department of Publio Works and other applicable permit granting authoritles.
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