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23B-056 (3) BP-2023-0508 30 BERKSHIRE TERR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-056-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-0508 PERMISSION IS HEREBY GRANTED TO: Project# GARAGE 2023 Contractor: License: Est. Cost: 65000 WILLIAM LAMORE CS-076123 Const.Class: Exp.Date: 05/23/2024 Use Group: Owner: CLARK, THOMAS R&JEANNINE CLARK Lot Size (sq.ft.) Zoning: URB Applicant: LAMORE LUMBER CO Applicant Address Phone: Insurance: 724 GREENFIELD RD 413-773-8388 6HUB0248N15A22 DEERFIELD, MA 01342 ISSUED ON: 04/27/2023 TO PERFORM THE FOLLOWING WORK: BUILD 24X28 GARAGE WITH 2ND FLOOR LOFT 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Ci,f\dILL ,Ckeo Fees Paid: $134.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner File # 7 APPLICANT/CONTACT PERSON:CLARK, THOMAS R&JEANNINE CLARK 30 BERKSHIRE TERR FLORENCE, MA 01062 PROPERTY LOCATION 30 BERKSHIRE TERR MAP:LOT 23B-056-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $30.00 Type of Construction: ZPA -24X26 GARAGE WITH 2ND FLOOR LOFT FOR STORAGE New Construction Non Structural Renovations 30 Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement orLicense 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 7 INFORMATION PRESENTED: a'5 V Approved Additional permits required (see below) f LL >>L PLANNING BOARD PERMIT REQUIRED UNDER:§ tk\P vqg (.„‘ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan \‘ ? Y 6111 / MajorProject: Site Plan AND/OR SpecialPermit With Site Plan �� ZONING BOARD PERMIT REQUIRED UNDER: § • Finding Special Permit _ Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Perm its Required: Curb Cut from DPW Water Availability SewerAvailability Septic ApprovalBoard 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 ,614Ak., Till i/2-02 Sign ure 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. The Commonwealth of 1VXassac usett!P 4.1# 11. Board of Building Regulations an ,Standards ` <9Q ' FOR ' �p MUNICIPALITY Massachusetts State Building Codes USE Building Permit Application To Construct, Repair,Rene N P mulish a Revised Mar 2011 One-or Two-Family Dwelling ,_o;0 o�0,vs This Section For Official Use Only Building Permit Number: ->3 ,50 g Date Applied: ____illy\iitioN., :It--,A y � 03 BuildingOfficial(Print Name) Signature 1 / to � SECTION 1:SITE INFORMATION 1.1 ro erty.l.kyress c 1.2 Assessors Map&Parcel 117,bers 1.la Is this an accepted street?yes r< no Map Number Parcel Number 1.3 Zoning Information:/,41R-�GY% 1.41 Property o DiOmcnsions: l 0d, 6 Zoning District Proposed Use Lot Arta(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public if— Private 0 Check if yeses Municipal I6-On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' f_r n/' f Record:__A a .. _ rC.JC.4154 c w�12ntiv t &) /l.l A ``'11T�GGt�.66�i �s � MN WC (�f1'GY` i"l Name(Print) City,State,ZIP V I O C v_ 3 o f3 El S Fh R-r: 5-Ag1.501 !`i tomm tt�l l ttc Q �,�tni No.and Street Telephone mail Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. Eir. Number of Units Other 0 Specify: Brief Description of Proposed Work' ( 4 j —`( Z� C e�'4-C& �I 'jl "6-00i- LtxT SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 6o/ 0 e.b 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ��� ❑Standard City/Town Application Fee t 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 14(A 2. Other Fees: $ 4.Mechanical (IIVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Feesr: e7j�1.� Check No./•�7IQQCheck Amount: I Cash Amount: 6.Total Project Cost: $ 64,00 O 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number 1 Expiration Date Name of CSL Holder ! ' v C b ..�ACte Wat k/F List CSL Type(see below) V _ No.and Street Type Description G ■ /f„G� �4 Ci !3Q ( U Unrestricted(Buildings up to 35,000 cu.ft.) —�{ /6 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Rooting Covering WS Window and Siding t 3 P U 11t a2€li r 8 ,6'1 SF Solid Fuel Burning Appliances O $ I Insulation Telephone Email address D Demolition 5.2 Registered'' ) Home Improvement Contractor(HIC) (�O 05 t DI ct 12023 (�l/M !-,/t� g/-ten HIC Registration Number Expiration Date HIC Compagy�,latr or�e — ems W L-Amoi&O t) Tr l e Il t co* No.and S Ltregtl_�``-[„n y-'1 G j /4� q`3 1<3 (336,0 3,g Email address City/Town,State,ZIP ` C21-3 . Telephone SECTION 6: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 .O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I.as Owner of the subject property,hereby authorize 1 'l- it C to act on m�behalf,in all matt s relative to work authorized by this building permit applicati . l Y9 /` . 6Cibi / °" Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 714,E C b19,oz Z Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/batIts Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton 4 ;e:-- 4N, t A. ,,, Massachusetts ''c , , A DEPARTMENT OF BUILDING INSPECTIONS J 4, 212 Main Street • Municipal Building y�.. cam Northampton, MA 01060 rsjPi VOI CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: tfi.2thy aeC L( 2 ? Y C�f� a The debris will be transported by: AL4ete/L,.;f-- -772„,c.. 0 =— Name of Hauler: ql b, Signature of Applican . Date: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building R ulations and Standards ConskleontSvisor CS-076123 ,� *': � .t�JcAires:05/23/2024 WILL1AM R toll •" :�i►� 2S WASHBUMI GREEHFIELIy r`A0 41 r Commissioner Construction Supervisor Unrestrictsd-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space- Failure to possess a current edition of the Massachusetts $t Bul$ng Code is cause for revocation of this license. For information about this license Call(S17)7273200 or visit www.mass.gov/dpi ,l The Commonwealth of Massachusetts Department of Industrial Accidents t' ` 1- Office of Investigations :*= p 1 Congress Street,Suite 100 '-;'tiles' Boston,MA 02114-2017 '::,'.,,,,,.,,+1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Legibly Business/Organization Name:]Mite(d.., tU 1 Lorn R. .b La/more LUrnimr_th - Address: 1714 .Q ' 'k1:._.! - City/State%Zip: _I .A Q13 r .. Phone#: A 13- /l ig g3 b g Are ou an employer?Check the appropriate box: Business Type(required): 1. I am a employer with.__, ._. employees(full and/ 5. 0 Retail or part-time).' 6. ❑Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. 0 Non-profit [No workers'comp.insurance required] 3.❑ We are a corporation and its officers have exercised 4. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required)*" 1{.0{{ealtt Care 4.❑ We are a non-profit organization,staffed by volunteers, t with no employees.[No workers' 12.► Other comp.insurance req.] ,. *Any applicant that checks box al must also fill out the section below shoaling their workers'compen ion policy information. .*li'the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. l am an employer that is pravl g workers'compensation insurance for my employees. Below is the policy information. Insurance Company Namee:,� sox 11 �SU i.- ' Insurer's Address: EV• t�:l�-'x _ .,....._.__., ,...._._.... _...___ . City/State/Zip:--w t+L _tifi ....._L22o.6- -...4_._ Q W }_.._ Policy#or Self-ins.Lie,# (DWI&02'6 1 s— - -....--Expiration Date:O, 0 2DZ . Attach a copy of the workers'compensation policy declaration page(showing the policy number nd ex iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lea to the imposition of criminal penalties of a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in a 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 state t may be forwarded to the Office of Investigations of the DIA for insurance coverage veriication. - /do hereby certify,under the pains and pen ies of perjury that the in/rarrnntiotr provided above is true and correct. `� % _._.- Sinat�lre: `�'� `"" Phone#: "i5�_r l l • d .. . ..... _ ___.__ Official use only. Do not write in this area,to be completed by city or town official. City or Town: ._._...._..^.._...___._.._.�...__, Permit/License *_ Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Lice sing Board 5,Selectmen's Office 6.Other ..-- Contact Person: Phone __--- www.mass.govr'dia 1 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suit 710 Boston, Massachusetts 021 8 Home Improvement Contractor Re„istration Type: Individual Registration: 120052 WILLIAM R.LAMORE Expiration: 10/09/2023 724 GREENFIELD RD DEERFIELD, MA 01342 Update Address and Return Card. SCA1 0 20M-05/17 /// /' _� Ai icy of eonsurgt(l� f I iiiii�i;t�firiailon HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 120052 10/09/2023 1000 Washington Street -Suite 710 WILLIAM R.LAMORE Boston,MA 02118 WILLIAM R.LAMORE '2 724 GREENFIELD RD aefa ,', 4,04- DEERFIELD,MA 01342 Not valid without signature Undersecretary • • -NOTE- THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED c.„9. Cam' e t ' t . r c1 � y �n �LiZS dr- •v�A_.< <, oCI).co'� TO: FLORENCE SAVINGS BANK & TICOR TITLE INSURANCECOMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AKLA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY # 250167 _ —NOTE- SURVEYOR: +\ • -LQt_. THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY ��N of —MORTGAGE LOAN INSPECTION PLAT— 0 NORTHAMPTON, MASSACHUSETTS 2 RAND ALL 6s ,, PREPARED FOR ' ' THOM% S R. & JEANNINE F. CLARK o IZER N , /35032 1 SCALE: 1 "=30 ' APRIL 9 , 2nn3 ' e 1410 R -IO HAROLD L. EATON AND ASSOCIATES, INC. — REGISTERED PROFESSIONAL LAND SURVEYORS 235 RUSSELLI STREET — HADLEY — MASSACHUSETTS 1- C.L.P k ,3 13atzat-3 k it 2- i 2- - p Ij, ruoialst\icE tAfi ato i 1... .E .-4-rreae Fa .- u1 isi A 14 , i .t II 9 ` c;I ff. ` t ,_ ' i --..------E E , ; . .1 .\\?.___....___, 2 ktr--NIttlo r i" sou.d 6'004 { I" Sub F1 Ix iD FION-10( S 11 11 S_ g..,,,,4 -Com Culg4- ,. - - )c, . , 30ex,T Y.„Si"I‘re.! Itertret,re Vlore. tV 6. tr)0141:Nr I -r:•411 ,( PDS f V g, r - ep , 11111111111 111.1.11 iiiiiiiiilliN _ 1 1 , _1 I, 4 I * 1t ; -4, 1 , t i ' I I 1 1 1 1. 1 ; ! - t i 1 1 ; . ; 1 i 1 .1 f O' (c4,8 1,...—,...... I ,a—wimumna—i—mi;ims. A,. pof,-"t•f iii' i ; i 1 i 1''Tit .., 4 , • , p q i 1 1 1: F 4 , if 11 .; i ; I:41 I 4 I . , I ., 1 i I ''', ' I .. I ... f. i p 4 I I! I- 4 )4 , I 1 § 1 t I ! I 1 4 f t • ,. ,. , I 1 11 ft 4 11 n 1 f'' t r , 1 , t , (1 f 4' r ...0.11.••• ' P4 I Itck:5' (1,-.14„- :9 .., y. . . Torn cAnar -..., in-I x 1.9 64 1.5 TArielcie., lo -baafftee' -reitzuve -Ati. Lutn6gk FuLcur Florlf::--tt6 PIA. t-.2!b -,:i H ka i-i44t-ek, (px8 --PosTs 444 Bettc.Ez,$ ,N. ,,:-., 2.XS R/IFTO?S Cou-Pre..lies ----›:,,,-, 11 xto Prreg 214,, .2.xio PtAry,,sts 0 , . -....„,,,, ,--'-'''''7 2 x le HA iLEC. ,,- *„.-- ' --,„.....„. .., i -,,,, I" Soiab Pcop ,------- i --, A t Ix to Rooe,iots,ft, i i r i 7. 41 ...., _7_,,7_____ ____ , ,: 1 LL...,, ol/ORtielikl) , ; 1,1 - 1 oveet-k6fg) I i I woe.... i3i •-•roo(.1.. * , i e2):' INITIAL ESTIMATE INFORMATION Customer Name: I U i r s_ &L6 , k— Date: )- ZL - 2 Mailing Address: ,6Dic5 ,( Q de/1/1.[d Building Site Address: ('454,0 Q Home Phone# Cell Phone#13 „J 0.- /0 L Email How did you hear about us? Using Shed For: Size of Shed/ Bldg? }( 21 S J i a_ ' S $ 211 5:56 66 Saltbox? Gable? Gambrel (+35%)? 1' 1 $ i +t 2.-1 QV Pitch Roof? ( 8/12 (+,15%) "10/12 (+25%) '12/12(+25%)6'&1 $ 2, lie b GU h }� Siding? B & B T& Groove Shiplap Horiz/Novelty $ Ij L-t?i �' (T&G in or outside?) (rough in or outside?) tt-i- Location/Size of Doors $ 1, 1 iU 61 iz-.2/1( -I NGLrirL,zr Location/Size of Windows $ 5i o Extras $ J7 t Vents? Gable($50 pair) / Ridge(4'pc®$25.00) . YES NO $ 5-55 G' Foundation/Blocks/Sono-tubes?. 1 $ ( i f ao5 Color of Shingles? White Tan . Black Gray Lot Cleared and Level? $ 1-1,0t 3ktiligit4 (generator maybe necessary $75/day.) Drive Next To Site? YES NO If No, Distance $ (p,q1-1 (subject to carry fee) Permits ready? YES NO =; Sup-Total $ Sales Tax $ Delivery $ pis„o I:tnitia lEstimateinformationo9 ROUGH EST,IIVIATE OTAL $ Hampshire Concrete 45 Florence St Job Estimate Leeds, MA 01053 Jim Yurgielewicz 413-586-7982 Phone: 336-0762 Date: 4/20/2023 To: Job Name/Location: Garage 28 Ft. X 24 Ft. Tom Clark Job Description Cost Concrete And Labor For Footings And 5 Ft. Walls $6,100.00 2#4 Re-Bars In Walls $325.00 4 In Slab With Wire Mesh $2,900.00 This estimate is for completing the job as described above. It is based on our evaluation Estimated Job Cost: $9,325.00 and does not include material price increases or additional labor and materials which may be Estimated By: Jim Yurgielewicz required should unforeseen problems or adverse weather conditions arise after the work has started. ......................... ________T, .. ,,, ,7 /7-------r$,... ,, i L............... f I Z 1 r 1 I ‘, , 1 51 1 j I 1 ' % loll 1 i low -. vor t - . I 44)IN i 7 qf i , • iiti -4 , „............ i 4AA ii•--, i r----- , , rot • t, ."' ,.....• ti i lb i x.... 7 / .... ...4. .....r 1 , ,,„.7:77 , •1 1 ,1 „Iti ; 1 . .......--._ if o 6 w 4 5 1 r4 V41,7tAA! JAN 1 xi29 File No. It y0 3 ` A30 • • . D ING PERMIT APPLICATION(0o.2) Please type or print all information and return this form to the Building Inspector's Office with the $30 filing fee (check or money order)payable to the City of Northampton r`Yt✓,/� 1. Name of Applicant: ,, / � .4 S i< Address: 3 0 �L""`�s/t ' C E Telephone: `l l 3 37 0 7 2. Owner of Property: SA- Address: 54- Telephone: S A 3. Status of Applicant: Owner > Contract Purchaser Lessee Other (explain) 4. Job Location: 6 P s" ` -'- a / ' 2``40V CG I Parcel Id: Zoning Map# Parcel# 23 B -060 District(s): In Elm Street District In Central Business District (TO.BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: PE.5 1 UN CE 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): off`{ !�.� Cs -� �i cti i w SC-1-1.ldj oit- Co(`-7— 7. Attached Plans: Sketch Plan Site Plan X Engineered/Surveyed Plans 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT 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 '( DONT 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) R':'Documents\FORMS\original\Building-Inspector\7_oning-Permit-Application-passive.doc 8/4/2004 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 PA IF YES, describe size, type and location: 11. Will the construction activity disturb (clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan of development that will disturb over 1 acre? YES NO 1; - IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building Department EXISTING PROPOSED REQUIRED BY ZONING Lot Size Frontage Setbacks Front ?,,,t -r - Side L: R: L: R: L: R: Rear -70 / Building Height ORl Building Square Footage /ivv5 /c 5t? rr' 3/tz-0 f y�- 54 Fr 5G2 �'" %Open Space: (lot area _ o minus building a paved fj 70 /3 parking #of Parking Spaces #of Loading Docks L Fill: (volume Et location) 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Date: f' /i J 114v2\"L Applicant's Signature NOTE:Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health,Conservation Commission, Historic and Architectural Boards,Department of Public Works and other applicable permit granting authorities. W:Documcnts\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004