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38B-024 City of Northampton a Massachusetts .4. ' �' DEPARTMENT OF BUILDING INSPECTIONS _' s1 212 Main Street • Municipal Building ti Northampton, MA 01060 S'''F. ., Roger Ball , 115 Glendale Road Southampton, MA 01027 38B-024 December 7, 2012 Dear Mr. Ball, I have reviewed your permit application to use your property at 24 Fort Hill Terrace as a three family dwelling. I have checked the building department records as far back as 1980. I have checked with the assessor's office. Other than the rental agreement you provided with your application, dated April 2010, I can find no evidence that the dwelling was ever permitted as anything but a two family dwelling. The lot size at 24 Fort Street is 5280 square feet. A three family dwelling in that that district would require a minimum lot size of 15,000 square feet under current zoning regulations. The zoning regulations in effect in 1980 required 12,000 square feet for a three family dwelling. The rental agreement from April 2010 does not establish a long term use as a three family dwelling. Without information such as financial records, rental agreements or sworn statements from prior tenants or owners establishing use of the basement as a dwelling unit prior to 1980, use of your building as a three family dwelling is a violation of the City of Northampton zoning ordinance. Please provide satisfactory evidence of long term use as a three family or cease occupancy of the basement dwelling unit. If you do not respond within 14 days I will take further action. Thank you for your cooperation in this matter. Louis Hasbrouck Building Commissioner City of Northampton (413) 587-1240 lhasbrouck@city.northampton.ma.us possession within 30 days from the beginning of said term, either the Lessor or Lessee may terminate this lease by giving written notice to the other and any payment made under this lease shall be promptly refunded. Lessee hereby authorizes and empowers Lessor to institute proceedings to recover possession of the premises on behalf of and in the name of the Lessee. 21. SURRENDER OF PREMISES: Upon the expiration or other termination of this tenancy, Lessee shall quit and surrender to the Lessor the demised premises in good order and condition, ordinary wear and tear excepted. Lessee also agrees to provide Lessor or his agent with Lessee's forwarding address. 22. LIABILITIES UNDER LEASE: In the event the Lessee herein consists of more than one individual,the Lessee's liability thereunder shall be joint and several among such individuals. In the event the Lessee herein consists of a legal entity such as a corporation,trust,or otherwise,the principals thereof hereby personally and in their private capacities guarantee compliance with all covenants and conditions contained in this lease. Said covenants and conditions shall bind and inure to the benefit of the Lessor and the Lessee and their respective heirs, personal representatives, successors, and assigns. 23. SEVERABILTY: If any provision of this agreement or portion of such provision or the application thereof to any person or circumstance is held invalid,the remainder of the agreement,or the remainder of such provision, and application thereof to any other person or circumstance,shall not be affected thereby. 24. WAIVER OF BREACH: The waiver by Lessor of any breach by Lessee of any of the provisions of this agreement shall not constitute a waiver of any subsequent breach by Lessee either of the same or another provision of this lease. 25. ATTACHMENTS: A copy of the TENANT LEAD LAW NOTIFICATION and CERTIFICATION FORM signed by tenant and landlord or managing agent is also attached. If applicable, a copy of a lead inspection report or a letter of compliance may also be included. Lessee as an individual states under the pains and penalties of perjury that said Lessee is over the age of 18 years. al...ow Lessee: Negl . Date: Lil(Via Mar,ters n �T Lessee: �%(i� Date: 01/13/ l o Margare Kurkoski Lessee: litiZ� , I rev Date: l 13j l 0 '1/ Aviva Jacobstein Lessor: Date: Roger Ball Lessor: Date: Linda Ball 13. NOTICE: Notice to the Lessor and Lessee shall be deemed given if mailed to the above addresses. All notices must be in writing and verbal notices are not effective as notice. 14. EVICTION AND COLLECTION: All eviction and collection proceedings shall be in accordance with Massachusetts Law. If this agreement is terminated for breach of its term or in the event of litigation,the prevailing party may recover its'costs and reasonable attorney's fees actually incurred and all rent due under this agreement. If the Lessee does not comply with any obligation imposed on the Lessee under this agreement, or if the Lessee admits being or is declared to be bankrupt or insolvent,or if the Lessee appears to have abandoned the premises,the landlord may terminate this agreement by written notification to the Lessee. The termination will become effective seven(7)days after the notice is given, except where the tenant fails to pay rent,in which case the termination will become effective fourteen (14)days after the notice is given. The landlord shall also be entitled to any and all other remedies provided by law. All rights and remedies are to be cumulative and not exclusive. 15. PARTIAL PAYMENTS: Lessee shall make all rental payments in full. Payment or receipt of a rental payment of less that the amount stated in the lease, including payments by one or more roommates, shall be deemed to be nothing more than partial payment on that month's account. Under no circumstance shall Lessor's acceptance of a partial payment constitute accord and satisfaction. Nor will Lessor's acceptance of a partial payment forfeit Lessor's right to collect the balance due on the account, despite any endorsement, stipulation,or other statement on any check. Any modification to this lease must be made in a letter signed by the Lessor, in which the Lessor states and agrees to the modification. The Lessor may accept any partial payment check with any conditional endorsement without prejudice to Lessor's right to recover the balance remaining due, or to pursue any other remedy available under this lease. 16.NOTICE TO VACATE& SECURITY DEPOSIT: Lessee shall give the Lessor at least one month's written notice to vacate. Security deposit is accepted as security for the full,faithful and punctual performance by the Lessee of all covenants and conditions in this lease, including but not limited to any unpaid rent which has not been validly withheld or deducted. Lessee may not use security deposit as rent. 17. INSURANCE: Lessee agrees to carry and maintain,while leasing these premises, both liability and property damage insurance for its leasehold interest. Property brought into any part of the leased premises by the Lessee or any person with the Lessee's knowledge or consent shall be brought in at the sole risk of the Lessee. Lessor shall not be liable for property of any kind which may be lost, stolen,damaged,or destroyed by fire,water, steam, defective refrigerator or otherwise while on the leased premises or in any storage area,hallway or basement area in the building, unless caused by the Lessor's negligence or misconduct. Lessee shall not commit or permit the commission of any acts on said premises nor use or permit the use of said premises in any manner that will increase the existing rates or cause the cancellation of any fire, liability or other insurance policy allocable to aid premises. Lessee shall comply with any and all requirements of Lessor's insurance carriers. Lessor agrees to maintain, at its expense, liability and property damage insurance on the building of which the leased premises is a part. Any insurance proceeds received by Lessor shall be the sole property of Lessor, free from any claim by Lessee. 18.NON-LIABILITY OF LESSOR: Lessor shall not be liable for any injury or damages to persons or property within the Lessee's leased premises, or for any interruption in the supply of any utilities or the interruption of access to the Lessee's leased premises or any portion thereof if caused by circumstances beyond the Lessor's control. 19. LOCKS: The existing locks shall not be changed,altered or replaced nor new locks added by Lessee without the express written permission of Lessor. Any locks so permitted to be installed shall be come the property of the Lessor and shall not be removed by Lessee. 20. DELIVERY OF PREMISES: In the event the Lessor is unable through no fault of his own to deliver the leased premises to the Lessee at the time called herein,the rent shall be abated on a pro-rata basis until such time as occupancy can be obtained,which shall constitute full settlement of all damages caused by such delay. Otherwise,the Lessor, at his election, shall be allowed reasonable time to deliver possession of the leased premises,and if he cannot deliver such 10. LESSEE OBLIGATIONS: The Lessee agrees to the following: A. To pay rent on time and use the premises as a residence for no more than four(4) persons and not as a place of business and in compliance with all applicable laws and codes. B. To make no alterations or improvements to the premises, including painting,without the prior written assent from the Lessor. C. Lessee is responsible to place garbage and refuse in containers and to prevent any unsanitary conditions from arising on the premises; and to abide by all local and state health, sanitary,recycling,and refuse disposal regulations;Lessee is to be responsible for all fines or damages to Lessor as a direct result of Lessee's failure to abide by said regulations. D. To give Lessor prompt notice of any maintenance or repairs that are needed and to immediately notify Lessor of any absence of heat. E. To respect the needs and rights of other residents and neighbors to the quiet and peaceful enjoyment of their property. Complaints regarding noise or offensive conduct including but not limited to loud arguing,radio,television,or stereo, may constitute sufficient grounds for eviction of the Lessee at the option of the Lessor. Please be a respectful neighbor. F.To reimburse Lessor for any repairs due from damage, structural or otherwise,which become necessary by reason of the negligence or willful acts of the Lessee or his or her agents, servants, invitees,employees, or other persons related to or affiliated in any way with the Lessee including any damages from a pet. G. Lessee, occupants, guests, family members,or other persons related to or affiliated in any way with the Lessee shall not engage in any unlawful activity which include,but is not limited to the use and/or sale of alcoholic beverages by or to Lessee, occupants, guests, family members, or other persons related to or affiliated in any way with the Lessee not of legal age or intoxicated, and the use and/or sale of any narcotics or other controlled substances. H. Porches,halls, stairwells, stairways,or other common areas are not storage areas unless so designated in writing. Storage in these areas is not permitted. Personal property placed in these areas may be disposed of at Lessor's option at Lessee's expense. I.Lessee shall not have large gatherings or parties without prior written notice to Lessor. The number of guests may not exceed four(4)without prior notice. Such receipt of notice by Lessor in no way implies Lessor's consent or liability for the conduct,actions,transportation to or from the gathering,or damages by the Lessee's invitees,their guests,whether invited or not to such gathering; Lessee assumes full and complete responsibility and liability for all damages to said unit, to the Lessee,their invitees, or to guests,whether specifically invited or not. J. Personal property or furniture may only be left in the Leased Premises for the next occupants with the prior written assent of Lessor,and signed approval of present Lessee and subsequent occupant. Any property left without such signed agreement shall be treated as abandoned property,the removal of which shall be at Lessee's expense. K. To prohibit pets from the premises,whether owned by Lessee or guest or visitor. L. Parking available—one spot closet to unit entry. Failure to observe the foregoing provisions of this lease shall operate to TERMINATE THE RIGHT TO OCCUPY UNDER THIS LEASE for breach thereof,at the sole discretion of the Lessor(and any waiver of any breach at any time shall not constitute a waiver of any subsequent breach)and the Lessor is not required to give notice thereof to the Lessee(s) except as required by law,and if law is not specific,seven (7) days notice to Lessee(s)shall be deemed sufficient. If this lease is breached by the Lessee(s)and the Lessor elects to terminate the Lessee(s) right to occupy the premises as a result of said breach,Lessee(s)shall be liable for all rental obligations that accrue under this lease if the premises remain vacant,or for the difference in the rental charges in any new tenancy,until the end of this lease term. 11. RIGHT OF ENTRY: Lessor shall have the right to enter and inspect the premises and make repairs and necessary improvements and to show the premises to prospective residents or mortgagors. Lessor shall make a reasonable effort to notify the Lessee before such entry. Lessee agrees to cooperate regarding showings. 12. COPY OF THE LEASING AGREEMENT: Lessor shall deliver a fully executed copy of the Leasing Agreement within thirty days of receipt from the Lessee. Tenancy at Will Agreement LANDLORD COPY LESSOR: Linda and Roger Ball 115 Glendale Road Southampton,PO Box 180 01073. RESIDENT/LESSEE: Aviva Jacobstein, Marya Peterson and Margaret Kurkoski PREMISES: 24B Fort Hill Terrace,Northampton,MA 01060 consisting of 4 rooms, 2 bedroom and 1 bath. 1. RENT: The leasing term commences on April 23, 2010. Rent amount per month is $1,000.00 payable in advance, due on or before the first day of the month. This payment must be paid in full in one check or money order. 2. LATE RENT: Please pay your rent in a timely manner. If rent is not paid before the 5th of the month and no other arrangement is made in writing with the lessor,a 14-day notice to quit will be delivered,and the sheriffs fee will be charged to the Lessee. In the event the rent is 30 days past due,a$25 late rent penalty shall be assessed. There will be a $15 charge for checks returned. Tenants must pay rent in one check. 3. SECURITY DEPOSIT: Lessor acknowledges that it will receive a security deposit of$1000.00. Accrued interest for last month's rent and/or security deposit shall be paid to Lessee at the end of the tenancy. Your security deposit is located at: 4. UTILITIES: Lessor shall be responsible for all utilities. Lessee shall be responsible for any cable, phone or Internet utility. Lessee agrees to have no more than one air conditioning unit installed without approval of Lessor. 5. CARE OF PREMISES: The Lessee shall not paint, decorate or otherwise embellish nor make any additions or alterations to the premises without the prior written consent of the Lessor. No space heater,television or other antenna, washer,dryer, dishwasher or other appliance shall be installed without the prior written approval of the Lessor. The Lessee shall maintain the leased premises in clean condition and agrees to be responsible for any damage caused to the premises by the Lessee or any person under the control of the Lessee,except for reasonable wear and tear. Entry may be made without prior notice in emergencies or if the premises appears to have been abandoned or upon court order. A move-out inspection to determine damages beyond wear and tear will be conducted prior to the termination of leased tenancy. 6. APPLIANCES: Lessor shall furnish the stove and refrigerator for the tenant's reasonable use.No Laundry. 7. CARE OF PREMISES: The Lessee shall not paint, decorate or otherwise embellish nor make any additions or alterations to the premises without the prior written consent of the Lessor. No washing machine, air-conditioning unit, space heater,clothes dryer,television or other antenna shall be installed without the prior written approval of the Lessor. The Lessee shall maintain the leased premises in clean condition and agrees to be responsible for any damage caused to the premises by the Lessee or any person under the control of the Lessee, except for reasonable wear and tear. The Lessee agrees to maintain electric and heating services to prevent frozen pipes. Entry may be made without prior notice in emergencies or if the lease premises appears to have been abandoned or upon court order. A move-out inspection to determine damages beyond wear and tear will be conducted prior to the termination of tenancy. 8. MAINTENANCE: For all maintenance repairs,please contact Roger or Linda Ball 413-539-4224 9. LESSOR'S OBLIGATIONS: The Lessor agrees to the following: A. To make all repairs required within the premises. B.To maintain in good and safe working condition the plumbing,heating and appliances,to remove all ice and snow from all areas,to maintain the grounds,and to provide a dumpster for trash removal . C.To comply with all applicable local and state laws, codes and rules. Pipeline Specialists JOB 1E3P4 SHEET NO.: OF CALCULATED B : DATE Everett J. Prescott, Inc. SCALE .,,D,y 3 y a>4 i l l \/-8 r r L p\AbP ,,1- rte,. ti }} ■ t ,-iD j 0 _.___''', , , 1 t si ' R--'- J t 6 ' , ^ rte, 6\��'� j ! k a�-; \ DD C , ' S a Allot , 1 1 4 /A> 0 ''''.k4'4'., (,,), ,,., 1,3--k__J w G2� < � i $11 (_5)\' 1 - L N\ (7 4-,s.. C cri WI,Mj6�a SC a.FP te, u 4 0,, 177 ,,., The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 600 Washington Street Boston,MA 02111 ww d; emu, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractor 6. ❑New construction 2.C1 I am a sole proprietor or partner- listed on the attached shee 7. ❑Remodeling ship and have no employees These sub-contractors ••.ve g_ ❑Demolition working for me in an .•.aci employees and have orkers' g ty. 9. ❑Building addition [No workers'comp.insuranc comp. insurance.$ required.] 5. ❑ We are a corpo •tion and its 10.0 Electrical repairs or additions ffi ocers have their Plumbing repairs or additions 3.CI am a homeowner doing all work ave xerc r 11.❑ myself. [No workers' comp. right of exe ption per MGL 12.❑Roof repairs insurance required.]t 152, § '4),and we have no emp • =-s. [No workers' 13.❑ Other comp. i' urance required.] *Any applicant that checks box#1 must also fill out the section below. owing..eir workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing al work and th hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet s owing the name e the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must pro de their workers'co .policy number. I am an employer that is providing workers'comlensation insurance for employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: `, Job Site Address: City/State/Zip'- Attach a copy of the workers'compe sation policy declaration page(showing the policy num r and expiration date). Failure to secure coverage as required/Under Section 25A of.MGL c. 152 can lead to the imposition o riminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . I , • Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 11011) Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. _ Signature of Owner Date I, Rca_ca. 2__/A 1.1 __ _ , _.._.__.___ ,as 10,uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains andpenalties off er'ug _ _ _w_. ___..� % .. -��.�. ..._. ... , ._____ _ _ Print Name ______.___.. ___.._______ _.___.___ Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder. ...._ ... w.. -m._... _s..__....._.._ w___ .. __..„ ._ m..a r License Number -.,,, V Address W1___ �, __ _...._.__.__,_._....�:.� Expiration Date Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.15 , 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 0 No 0 1 Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION!SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000C.F.OF EN, LOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): ___- W�M Registration Number . . .....__ _._...._..._..__ _ _ Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date i Name Area of Responsibility Address Registration Number -7 r Signature Telephone Expiration Date Name _ . ��___.. -.___- - _, Area of Responsibility , I s Address Registration Number Signature Telephone Expiration Date ____..-..____ ---- Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Company Name: _.�.�.____._.�. ..______�..._..�. _ M._..___-._.-. _..�..__„_____..._._ Not Applicable ❑ Responsible In Charge of Construction Address__ Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON.ZONING , Existing Proposed Required by zoning , This column to're filled in by Building Department Lot Size I :.._. ...,_ _. „" Frontage Setbacks Front Side L: R:R: . L.. R:. . Rear Building Height '" Bldg. Square Footage o/ r."._".._ °"" Open Space Footage , % — (Lot area minus bldg&••ved : Version1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 , CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Exis ng.Wall Si g ns ❑ Demolition❑ Repairs❑ Additions 0 Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Brief Description ;Enter a brief description here. Of Proposed Work ES-IA g i ' r- 1 �t 3 — 'bou6c.�i� _.uNTi.. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 0 A-2 0 A-3 0 1A � ❑ A-4 ❑ A-5 ❑ 1B 0 B Business ❑ 2A ❑ E Educational ❑ 2B " r ❑ F Factory ❑ F-1 0 F-2 0 2C ❑ H High Hazard ❑ -- _ — 3A ❑ I Institutional ❑ I-1 0 1-2 0 1-3 ❑ 3B ❑ M Mercantile ❑ 4 0 R Residential ❑ R-1 0 R-2 E21 R-3 0 5A ❑ S Storage ❑ S-1 0 S-2 0 5B I \XI U Utility ❑ Specify: M _ _ .__._.____ M Mixed Use ❑ Specify: �__�_. __ __. S Special Use ❑ Specify:, COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: ____ ___ . ; Proposed Use Group: _ Existing Hazard Index 780 CMR 34): _ __,.,_.. _. Proposed Hazard Index 780 CMR 34):_ _ __. __, ____, . SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) ' s 1 sc 1st , .,..«..._. ,,.......-..,.G.-__ ____. 2nd i 2nd _..__ 4th 4m , -,� Total Area(sf) Total Pr.dosed New Construction(sf __ Total Height(ft) __ Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood one Information: 7.3 Sewage Disposal System: Public 0 Private ❑ Zone _,,,„T_,____ Outside Flood Zone❑ Municipal ❑ On site disposal system R f� Version1.7 Commercial Buildin Permit May 15,2000 `" -1 ! City of Northampton t t w ` .y., 4 Building Department /5 pew . , I: 2012 212 Main Street Se ®: *11 i Room 100 �,t- / 1 a ° ` ; t ;, ; ' ,4 Northampton, MA 01060 '6. t ff` DEPT.OF BUILDING INSPECTIONS p s i ® m Utg,P , -A�4 t. NORTHAMPTON,MA 010 c "..5,' ,r ., zk , Z -. �LZOao-113-587-1240 Fax 413-587-1272 Pk ,- s �, fte x .1 xi a'a:",sq"., .- ;. a,. - ..i,'.. ;tek$ APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: _op_erty This section to be completed by office .�.���nt el-6( j-0. J // n�L re/4-tie Map Lot Unit SOY T'h�' M e 0) 10'13 i Zone Overlay District °._° -. °. -.M _ .. -,' Etm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ Ger 2_1084 31' i i�@ fox t Sau-�i.� a r>7a aea73 Name(Print) _mw.... __.__.. „_� mm � Current Mailing Address:µ _."^ R �r 13a 1 v i3: Ls�r�,-5.7.576,_i____, Signature Telephone _ ,_.. 2.2 Authorized Agent: Name(Print) Current Mailing Address: _ __w y_. __... w_ . 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 v 2. Electrical ----7����� ��� - (b)Estimated Total Cost of ". Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) --•-----•--�--_ 5. Fire Protection _ ,..__.,._ _,_ ..,_._.._.w 6. Total=(1 +2+3+4+5) Check Number / / V [ y This Section For Official Use Only Building Permit Number Date . Issued Signature: Building Commissioner/Inspector of Buildings Date Lk)it i. gQ4,,i.)1 CHECK A D oat pJtc,"T R T la A / PLA 05 File#BP-2013-0636 1400 Leiree �I 7 APPLICANT/CONTACT PERSON BALL ROGER A&LINDA J P 0 BOX 180 �� � ADDRESS/PHONE 115 GLENDALE RD SOUTHAMPTON (413)446-5561 Q 1b 601 PROPERTY LOCATION 24 FORT HILL TER I Nfo r i? 10,)J MAP 38B PARCEL 024 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /402/� Fee Paid V Typeof Construction: ESTABLISH 3RD DWELLING UNIT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 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 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.