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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. fO Alterations
NORTHAMPTON, MASS. 19 Additions
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APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location Lot No.
r'-
2. Owner's name Pet n Address P,1 c� C -
3. Builder's name Address ( a <5 z- 4
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alterations r'r
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 k e u L
13. Siding house
14. Estimated cost- 5 Z c o
r
The undersigne rtifies that the above sta is are true to the t of his, her
knowledg d,be ief. /r-7
Sign`re of responsible cant"
Remarks
e
g'CHMIPT
(((r�
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�� a� GYtt� of 'Wart4a l pion Z
6 �iasaacl{nsrtts
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
cipermwittze)
with a principal place of business/residence at:
(phone#)
(street/city/statrhip)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
c/)h -s/)s .
-
1 a �? CCU _2 Il c7
(Insurance Co ) (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:
q s�
am e of Con r) (Insurance Company/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneceaary to include informaiioa pertaining to all coat=ton)
( ) I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing alt the work myself.
NOTE:please be aware that while homeowners who employ pecans to do mairdcnaa cc�const action or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thercw are:not generally cowidcrcd to be
employers under tbo wor lugs o=pc:nsation Act(GL I52,ss 1(5))�,application by a homeowner for a license or permit(nay evidence the
legal stahra of an employer under the Workees Compensation AcL
I undessund that a copy of this rut=3mt may be for wardod to the Depwt.�of Indu3trial A=&a&Office of Insauame for the
coverage verification and that failure:to segue coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
ooenisting of a fine of up to 51,500.00 and/or imprison of up to one ytw and civil penatties is the form of a Stop Work order and a
fine of S1oo.00 a day against tae.
Si � of
1997 For dTutmc use only
Permit Number
i Ilk C` �' ' Map# _Lot#
Sivvtum of Li
10. Do any signs exist on the property? YES NO G's
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 COMPLE'T'ED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This cola= to be filled in
by the Banding D rpartmen t
Required I
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
f of Loading Docks
Fill:
4 vol-ume--& location)
13 . Certification: I hereby certify that the inf 7ation cont in herein
is true and accurate to the best of my kn led
DATE: APPLICANT's SIGNATURE
r
NOTE: Issuanoe of a zoning permit does not relieve an lioa to burd n to comply wltla��pll
zoning requirements and obtain all required permits from the Board of Health, Conaervation
Commission, Department of Publio Works and other applloable permit granting authorities.
FILE #
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: T)
7 (� U
Address: (� �� .�c`.,E� �b�ue� ��(�- Telephone: ��L{J C
2. Owner of Property: �4 r . R M r
Address: �n p �'( C -{ Telephone:
3. Status of Applica . Owner Contract Purchaser Lessee
V Other(explain): njr� � �•`
4. Job Location: e, ,11: 11 (
Parcel Id: Zoning Map# 3 Parcel# 3 District(s): a/e
(TO B FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property ,i I& z (I r 4>
6. Desc 51 on of Proposed Use ork[Prcject/Occup/apon: (UsJ ad ''onal eets 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 bee issued for/on the site?
NO DON'T KNOW �X 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 Doc ent#
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)
FILE # ; J 4
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o
APPLICANT/CONTACT PERSON:/--)
ADDRESS/PHONE:
PROPERTY LOCATION:
MAP 3 PARCEL: ��� ZONE �' �r1 S
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
e
Ile
Fee P!l
Fee nid *I
Additinn to Existing
Building Plan-, Included-
u
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 Conservation Commission
A!:
Signatur o ate
NOTE:Issuanoe of 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 authorities.
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