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17A-092 (5) 22 GRANDVIEW ST BP-2020-0221 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 17A-092 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:KITCHEN&BATH RENO BUILDING PERMIT Permit# BP-2020-0221 Proiect# JS-2020-000365 Est.Cost: $39860.00 Fee:$259.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MICHAEL PHILLIPS 082683 Lot Size(sg. ft.): 11630.52 Owner: DIMMITT CATHERINE L C/O BRIAN P TOOHEY Zoning: RI(100)/URA(100)/WSP(15)/ Applicant. MICHAEL PHILLIPS AT. 22 GRANDVIEW ST Applicant Address: Phone: Insurance: P O BOX 514 (413) 250-7990 () WC GOSHENMA01032 ISSUED ON.812112019 0:00:00 TO PERFORM THE FOLLOWING WORK.-KITCHEN AND BATH RENO POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: 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: FeeType: Date Paid: Amount: Building 8/21/2019 0:00:00 $259.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0221 APPLICANT/CONTACT PERSON MICHAEL PHILLIPS ADDRESS/PHONE P O BOX 514 GOSHEN (413)250-7990 Q PROPERTY LOCATION 22 GRANDVIEW ST MAP 17A PARCEL 092 001 ZONE R1000)/URA000)/WSP(15)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: KITCHEN AND BATH RENO New Construction Non Structural interior renovations Addition to Existin Accessory Structure Buildine Plans Included: Owner/Statement or License 082683 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR' Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 9-21- Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Department use only City of North mpt n of P rmit: Building Dep rtm nt Curb ut/D iveway Permit 212 Main tree AUG 2 7 201 Pew r1Sep is Availability Room 1100 Wat rM/el Availability Northampton, MA 8,4FSU1L Sets f Structural Plans INSPF WWite � ans phone 413-587-1240 IFax41_ - 8944 PAA 01 d. ify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6(2- ?�-­xa--/ 1.1 Property Address: This section to be compl ed by office Map Lot � Unit 1� ,AV 4� ( Zone Overlay District ` 1 Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Priv , Current Mailing Address: Telephone Signature 2.2 Authorized A ent: ukfk G Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (0 SG(� (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) �J 9 5. Fire Protection 6. Total = 0 +2 +3+4+5) Check Number This Section For Official Use Only Building Permit Num r: Date Issued: ` Signature: Building Commissioner/Inspector of Buildings Date The Conirnonivealth ofMassachusetts Department of Industi ial Accidents Office of Investigations V-0 I CongressStreetSuite 100 Boston,MA 02114-2017 it iov.rnass.govMia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business Organization Individual): T, Address: City/State/Zip: Phone 4: Are you an employer. heck the appropriate boa: Ty a of project(required): 1.El I am a employ er with -1• ❑ I am a general contractor and I employees (frill and/or part-time). * have hired the sub-contractors 6. ❑New constriction 2.❑ 1 am a sole proprietor or partner_ listed on the attached sheet. 7. KRemodeling ship and have no employees These sub-contractors have S. ❑Demolition workingfor me many capacity. employees and have workers' 1 9. E]Building addiiioii [No workers' comp.insurance conip. insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. ri&of exemption per MGL 12.❑Roof repairs insurance required.] fi c. 152.`1(4).and we have no employees. [No workers' 13.❑ Other comp. insurance required.] • policy In +••'--------- - ti'f d, ,fli ,,t ,nt,,a ,c,,,,, t cr,}uTt+_t t�.�;i-affidavit indicating such. tavu.cit:uc«ti tiv uiliui ii1L'�: 1daCit lIIdlCatilly fhCT'art t ina 3�l�1't anti fhzn tllrc i t_t:td�Ct____ th—t ,', , :^w" -t �w- -d l:ti ..:.!-,'„-t eh^ 'ti­ f the sats-contractors and state whether or not those entities have .:.y.,.,-4 s.c`.... .......:i....�sb..a'-.'c :s}•liv,-it _�--- `t==``='•n t4;Pli .d:rl, •c•:alnp.policynumber. -- i"zog"ji c,. .i: :, c'sitsi s :`isrdssai• 's'rvr'r�icry i i!!i" �' &SUTance oT my em to ee& Beloit/is thepolky andjob site Tnchrnm_P(',amiamr NarnN'__F_ r cJ + E:�piration Date: 7k bshink)dTob Site Adress: _Cut\'/State/Zl�i: Qi :'ii i3 r t czas 1zia$es�aua=spa -=r-==r' —=limit n€'ctiaj:i�.xuv31date). �::.i::::'.�.. - --' - _. t - =h aT'ir,i , ,. �-•al i t<:!4 -1ti�11 l•f.�ru`llu. rattles Of a - -.—'._- -- ------- --"c - - . --- `— -- -- - ----- - -II -- - - site:: - 19 pt' tine rip t =$1,=n^.^'?a nd' r 11 i ca wari.onlment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be fort`-arded to the Office of Investigations of the DIA for ins7uur^*•�— = �r_,p„l er;�,,-,+;.,^_ Idoh � r. .ti,-!.t 4 '_.' °` 4X.o tl i1JJ. it-•i: :-:;- '_-t ::" -- .: d - � i7l - :af -.i axes SignatuDate- k Vim/ 1 1 Phone#: ' G� s.��_-�_.. --- _:;.__�__..�..---=--=-- �"—, � :..max_ - — - — <• Official use or j; Do nor n7 tv in th f#`i'+i,to I,-za,Pr.'tr'1r.Jb,) i7 j`oir tL i"1 Cit"or ToT--n: Isming A uthorih•(eirelc. 1.Roardofl-IwCaME IPi1-1u..�,I= 3.Cif_.'Tu Ci: 1. E`_ ft : -, t__ S.P • ` t:„I..x to< 6.0(L• Confect PCIsiGn Pate;::11. .. `•� -� {t #.._ � 1. �» ..- .. -: C .. ... =a � t. s ,: - � �' .„ .. r �. ;` ... '� - .t �� .- a �� a .� f I .� _.- y .�, *n r. . �' y - �. .. .. ` rt ♦ - .. .. . .. ... � l ..� ., i... _ - --- ` - 11 � __ . . .» _ �. . -'y ., j - - .. City of Northampton Massachusetts I w DEPARTMENT OF BUILDING INSPECTIONS Dt 212 Main Street • Municipal Building Northampton, MA 010600 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (~before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed) insulation inspection (if required)and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location •''�''S :�� $ ituJ. ♦C�;FtJ3,m. .�3;%4i.di_L�:C�`�f �. ,'i)f! �:�.t;ii.� rt�31 _......:. .....Xw..... ... ......,..�.... ..,.., .:_. ...._ r..�«,......ter......—+,..�... _.._ .__ .,__.. .. mu 1w ...:. � • • tr .tl: 'lJ ...I AR A .`:'- !'JIC3. �# & �'J^ {X•'' Z .i i•Ix,drtget G,• ♦ :y.'!7!Cy _`3i r. .•.i , 't"�, � ,0 a,:CC:`.'. -.c,..'" •t`'}`:' ,ty f:;'z�Y ♦'.. .* y..`?' 11 J^ :-.'Tt':+- ..,Yt `"' f ::4g 1 P ... S, .; .. ;�, -c.`��°.�Xt g t� . ;t is: ar' RC1{)� _ 1 r>S'`i�•`' .a tJ :�� .X „�;, :?, t..,^ciG., .:`•+. 'i, ke 'la-.-°„ S+�A�?F•6C.�:f/'e..e z;"il.a:.sd��l�tt F�� �f,3pC�f ''.'�t,�'«�t€! i .a'�;;x � .. _J } -X4 e t� �e. {, � h', i�„`.'�'�} Y ,. '�� -s; ,,s, ♦pf,t,, :�! J.! �:� 1.;��C' .C... J ..,�'a„ j. t',.st t�;:,,, � f>�3. ;la''3+ezCl'�., 'fJ.F4 tLn' .Y4�1'M�,. i.`�. '4 1_'',1:1's��fl S.f/r�t{ i..�:'.,� 1. F?fi l,'f.; i.^ - 4T h �t -: - ♦ AGO t,i IgMj d Mb LM ; ,. g'.�►�.,.lt�'ri . .;- ��+lt'r�SA w{`..t;e# t;.13Jjctg:., ± �"����;,;;E�'.:ti�sl.} � . , ,P ijti�?�`� !'i`. +.1�-'1) ,.sx E, GNt♦:i'"! 1;;•' `J..j ,>,+tip "s,. ', � �?j��' X1Jt;t1� �'!k .,•'�t'.!T ,I." 1 c.ir ,t ''` ”' '€)C' , � c ,.:,X. !' +'' fit. �.st,• ?;.,� G:i '�E 1.SL? l�l. >�'� i_ � .w .�:��}'���.w.Cf>..;d �A: '�•r' �-i=. y?�"` Sf'j t:'. '�, t�,�.. * t:'Ca +.! +s... 'k.)j }sJn 11 3. }i,+Et k 0 VOW non ' an°". 10 Pt. 9,00 F'r' rwr;,�,_,.'". !�`.-.a r:' ..1.!♦; t ;;. f'' r;.��,.yl�♦ .%f a. .. �: r\`. i.1+-•`'y�jl, }* �.�. u:s� X.' ,aWtx .. . .. , :'; i` , tt�C". .t�. ... �C+ .J 4> '�9r• _. `lY IYC:'.'t.' j.0.'' ;,i' - f�'t��.f `�'s_ J 'z.: `� �1'. . _ krt ,.:-� ,7". �'-: `y:•. h ` ;tl :. 4_� 'Rt,� 4�. t?''s 'F:u'tt` - ;i,. -' `vt °! n .`;(`":, c. -•,t♦ f. ,h; th 0' j( f �''♦�ils.l �f' .��t s � .t.. }' , y' ffJ{.. • Y J TT Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute.an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased emplover,or the receiver or trustee of an individual.partnership. association or other legal entity.employing employees. Howe-ver the owner of a dwelling house haying not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152.§25C(6)also states that"ever'state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s). address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees. a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have arty questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-in-airance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year.need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-7274900 ext 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 7-2013 www.mass.gov/dia W,1 P,;, tt tit _>•::..:: :�,... .:tt:.u�::'".;!>1;;.,.«........F•',+".'S.""w4•`_ '..'SS:i'.:'.u"Y:: ..'X•.'"Y1-„'GL"�'"Ma::i'L.�'.:':_d�9C'../R"'....,a":'.9167rv'g�pq�,-+'x'!r"7.. .,-.-.-K. ':+i't7�'ti"S•`.:.:.:_'."iT'A"'�L77:. .:2."=J'nY.'-'--'.:.^::SY'.�'-'.,..:; " Pri, :L:9, ;� al., r,. '•s.,. r:l ''. 4. :S#it x. ; Jrt ,"a:.7#`df.3:'.. .. -q•.Atr FJ"WN i� "'�..d..tx"t f! ?lit!•tlt�e t! Yt' } \ \:. 9. *.'.`e's»•:, .«tea'' i 't• , :�1 r. 4.f y _t .r: ,.'ti: !.`F ��P; .f,:. I'... 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'lr Jx:t• 2 ,-.a,e. :t- j '..\.i'. -�. .}ji t.. II,.f.J l.I`4�- ..��t vr1!'t AY !l t tf. +�,", f:r_\"fi , City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal �facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: �� The debris will be received by: V �` e (4 �v Building permit number: Name of Permit Applicant U� Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructions Supervisor: c Not Applicable R Name of License Holder: 1 ' 1 i 1 Yom'�[�/� /.1 C �1 License 4umber Zoo() Address `— Expiration TDa etet Signature "telephone 9.Realstered Home Improvement Contractor: Not Applicable)Uo 1 Company Nam / Regis ation umber dressExpire on Date FF\\ L cV c S �GOK Telephone l` G r— SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 1 0� Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [I3] Other[U Brief Description of Propose] �` ej — �r/ � 1�* r )��A /J Work: �, I(Ju J �/, v 6 ) �/ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes __No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property r hereby authorize umej to act on my bQh�'?-[f, in all matters relative to work auth rized by this building permit application. Signature of Owner Date c � as Owner/Authorized Agent hereby declar at the stat mems a information on,the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under Jhe pai=0� j PrintName 0 1`r ( y 6� (")� Signature of Owner/Agent Date ,-tyf7. � .•. �J11, ,:d - ,x. 1fe:i 10 ;p- -its.:*.. .,� ';h.• �?. ,.:,:'.y'itB,. _ iy:n':..t '+; iG a;, ri, 4. .,f.,i } .y `._ v y A. f> Fa{ $, �:Iu s F JtSVt:bP, t015 i _p. •J i r'Xr �;`+x. '�i:1ljE".. ...._ ^_ .._.— _P;.` :J!:bl ` 'a - �� .,.`i•s.Ac+ .aFJ M:' ...:8 -.. .._ .._ .- .-_ ...�. �":i;3:?f-FiF'?'..-r °ni �t:.. ..Flt j: ._ . -'L1V!iJ ...4-- - - _._ - .. _ :! 1�., ,.... .... _. .._ _._ _._...._ .. _ ._ 1 Flhtif?!fiU• .�' ;1' ,v -. ..-__ ... ;1:..81 r_ ..--. ... } ll Lit'hA c ,t-s ;t L; , .UJ'-(lfii;i�". i L Y:JO+y-,...i:4lf l'J 4W�',l..'{:.. 11 _ .. ., r f kJc.,�'_7 i3"?(�i,.r.,,... ..__^- E�- _. ... :-�.Jts s...�-. - i,rF{ �..• .... .. .. . ...,_.. - �t6; i t.._f# � ' 't. !� i .'•.0",V�•.i ts•yr 'S�H-. :!):'{� � �".`:'b''�aj,tt4Fgd1 c f-�. ,� � ... ,,.. ' { { L'C:'•L°4�.,! c_...«7 .1. 1..- �'S�`Jd"1 ryY•"�E7,,�;� Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be tilled in bv Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg R paved park-mg) #of Parking Spaces Fill: (volume&-Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW ® YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required.