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DEPARTMENT OF BUILDMG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
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(Iicensee/permittt;e} � --��
with a principal place of business/residence at:
?' ST La f'la V` <� (phone#) G .Z 2
(street/ci /statrizip)
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:
(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/Poricy 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)
(anaclt ad&tionA sheet ifnecessary to include information pataining to au ooatractors)
(L�II am a sole proprietor and have no one working for me.
( ) I am a home owner performing alt the work myself.
NOTE:please be aware that whilo homcaancn who employ pasons to do maiuteaance,suction or repair work on a dwelling of
not more than three units in which the homeowner resides or oa the grounds appurtenant thereto arc not gcaaalty ooesidacd to be
employ=under the wmkeez compensation Act(GL152,ss 1(5)),application by a homeowner for a licam or permit may evida—the
legal rtatus of an employer under the Workeea Compemation Act
I understand that a copy of this rtatcment may be forwarded to the Departmeo2 of Industrid Acadca&Office of lnseuanoo for the
coverage verification sad that failure to secure oovemp under section 25A of MGL 152 can lead to the imposltion of a=tul penalties
oornia n9 of a fine'of up to$1,500.00 andfor of up to one year and civil penalties in the form of a Stop Work Order and a
fino of S 100.00 a day against mc.
For dgwtwe —only
Permit Number
'' _ Map# Lot#
Signahire of LitserJP ttee e
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. � l Alterations
NORTHAMPTON, MASS. � 1°;i 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
J, Garage
1. Location �. vo�l, l / Lot No.
2. Owner's name 6�t_�t--t tj 01 T
h t3 C n �-1 07 e-// y Address 2 �. ��( (I /
3. Builder's name W We S rrn //74 sr S:d1Jq4 /-V A"a r/&11 Address 7` a 15 f"l�o r o-
Mass.Construction Supervisor's License No. q 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-16 �6
`E
The undersigned certifies that the above statements are we to the best of his, her
knowledge lief.
Signature 01 responsible app,icanl
Remarks
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 coluam to be filled in
by the Building 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
&paged parking)
# of Parking Spaces
# of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contain d herein
r is true and accurate to the best of my knowledge.
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DATE: .�.( t� APPLICANT'S SIGNATURE—/Issue oe a zoning permit does not relieve an a plioanYs bur to comply witl���ll
zoning requirements and obtain all required permits from the Board of Health. Conservtation
Commission. Department of Publio Works and other appiioable permit granting authorities.
FILE #
File No. 63/-/',S 4�-- t
ZONING PERMIT APPLICATION (§20 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: je 51'tad t,5
Address: 3 7` e 1�s� `Telephone:-_ G -2Z °7
2. Owner of Property: '
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser_L__—Lessee
Other(explain):
4. Job Location:
t
Parcel Id: Zoning Map# Parcel# District(s): zfft
(TO BE FILLED IN BY,�HE BUILDING DEPARTMENT)
i
5. Existing Use of Structure/Property `� ' ¢
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.
S. 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 C-' 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)
7 0
FILE # J V 1 3 4
APR 2 6 1998 _
APPLICANT/CO,ftACT PERSON:
A:DDRESS/POONE:
PROPERTY LOCATION:
MAP '`��/ PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT_ APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
lRivildin2 Permit Filled nia
Fe aid
3 ,Sets of Plans /'Plot Pinn
y -
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
fro on�at' olpm
- -� t 112 Z '
Signature of Building h6pector D to
NOTE:Issuance of a zoning permit does not relieve an applioant's burden to comply with all
zoning requiremanta and obtain a ti
all required permits from the Board of Health, Conservaon
Commisalon, Department of Public Works and other applicable permit granting authcritles.
ICS ; cam sCT
City of Northampton REQUIRED INSPECTIONS
} ,
BUILDING 1. Footings and Walls
DEPARTMENT 2. Structural Components in Place*
3. Complete Building*
No. 1486 Office of the Building Inspector
Zoning Form No. 963432 Date 4/22/98 Fee$20.00 Check# 2053
Page, 41 Parcel 8 Zone RR/WP Secticn 127 ❑ Yes ® No
9
*
THIS CERTIFIES THAT Western Mass Siding & Roof ing Plumbing and Electrical Inspections required before Building Inspections
has permission to install vinyl siding Inspection on Site—Foundations
situated on 45 Loudville Rd - Edmund Connelly Inspection of Plumbing—Rough
provided that the person accepting this permit shall in every respect Inspection of Plumbing—Finish
conform to the terms of the application on file in this office,and to the Gas Inspection
provisions of the Statutes and the Ordinances relating to the Construction, Inspection of Wiring—Rough
Maintenance and Inspection of Buildings in the City of Northampton.
Any violation of any of the temps above noted is an immediate revocation Inspection of Wiring—Finish
of this pemlit.Expires six months from date of issuance,if not started. Building Inspection—Rough
Note:A certificate of occupancy will be issued by this office upon return Insulation Inspection
of this card signed by the Plumbing,Wiring and Building Inspectors.
** Install per Manufacturer's information: windows,vinyl siding,roofs Building Inspection—Finish
and woodstoves Smoke Detectors(Fire Department)
Other
A15'� tic F3,k
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THIS CARD MUST D ONSPICUOUS PLACE ON THE PREMISES
Certificate of Occupancy•j
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