25C-101 ��11AHP.
� ! f�assac[iusctts
e
'DEPARTMENT OF BUILDINjG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFI]DAVTr
ticenseldiernlittee)
with a principal place of business/residence at:
411 :Del � 114 (phone#) s-
(Sb=Uci /stalrJup)
do hereby certify, under the pains and penalties of pedury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worlang 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 workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additlomt*bed ifnecenuy to=hrde information pertaining to an oodract=)
( am a sole proprietor and have no one woriang for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awaoe that While homeowners who employ persons to do m_kdcua nce,com uctioo or rweir vmk on a dvY4ft of
not moue they ttmos units is which the homeowner resides or oa the grounds apprutenaet tha+cto ate not generally considered to be
employers under the wodues compecu4ca Act(GL152,u 1(5)),application by a homeowner for a rtaea*e a perma tray evideaoe the
legal dutus*fan employer under the Wadca'a Compematiou Act
I understand that a copy of this statement maybe faswarded to the Departmms of Lm ustsid Aoci W&Oboe of ieswumce for the
oovaap Vaifiadon and that failure to scarce coverage under soctica 25A of MOIL 152 can toad to the impositiaa cfaimi W peaaltia
oo=Lewg of a fine bfup to si,iw.00 and/or i nKbouma t of up to one year and avui peodtia in the force cf a Stop Worts Order and a
Stile of 5100.00 a dry agpinst m�
_.-.._ Forle�aboeedaltsaoanly
e� Maps Lot
SiSnagmt:of Uccns&6Rermittce Me
Ic ro °
v v
7p m
3 ZO m
LO) O
Z q —1
-� m
a
I A
Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location �� el ^' Lot No.
2. Owner's name D` '"� `� Address �_Pi� �� st /f•s ,�1 �i
3. Builder's name \10.,4 d 6j'✓ 4 Z Address Lf 1 p6pdc- All i,d Lt, jl w i„ �cl
Mass.Construction Supervisor's License No. t Expiration Date_
4. Addition
5. 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 certifies that the above statements are we to the best of his
knowledge and belief.
nature of responsible app,icant
C.
(�
Remarks "ta t :,►�C fi•:, c5�
10. Do any signs ebst 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.
Thin calm= to be filled im
by tba Banding Department
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
f 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 k owledge.
DATE: ° l APPLICANT's SIGNATURE
'�-/=
NOTE: 11"uanoa of a zoning permit does not relieve an appiioant's b den to oomply wit"-all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applionble permit granting authorities.
FILE #
r _ e DEC 2 01999
x
File No.
VEI'T OF 8!;:
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: ��1 �+� fill Da G-J,a Telephone:
2. Owner of Property:
Address: + S ( - ;�, Telephone:
3. Status of Applicant: Owner �/` Contract Purchaser Lessee
Other(explain): ,
4. Job Location: 1� ��1
Parcel Id: Zoning Map# �S G Parcel# District(s):
(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):
J'
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 -r` 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)
�* A
37 GRANT AVE BP-2000-0603
'S#: COMMONWEALTH OF MASSACHUSETTS
,iap.Block:25C 101 CITY OF NORTHAMPTON
Lot:-001
Permit: Budding
Cate o :roofing BUILDING PERMIT
Permit# BP-2000-0603
Project# JS-2000-1078
Est.Cost:$1100.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVID NUNEZ 128305
Lot Size(sq.ft.): 5967.72 Owner: HART EDWARD J&JOAN M
Zoning:URB Applicant: DAVID N U N EZ
AT: 37 GRANT AVE
Applicant Address: Phone: Insurance:
67 YALE ST (413) 536-7191
HOLYOKE 0 1040-5 6 5 5 ISSUED ON:12122199 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE REAR ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/22/99 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo