Partial permit:..
S \ \.J G.L{ f~A\L~ ,/
VersionL7 Commercial
City of Northampton
Building Department
212 Main Street
" ~'" Room 1 00
(~ \ Northampton, MA 01060
phone 413~587-1240 Fax 413~587-1272
APPLICATION '·0 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 I
1.1 Property Address: This section to be completed by office
1(;j"'/J~10jJ'I<O~;} ,.""""~.,.""",, Map Lot Unit
7 flAY/1 u' /} hi.. (I) (lIP;;) Zone Overlay District
I---------------------------.=..;.; st. District CB District
SECTION 2· PROPERTY OWNERSHIP/AUTHORIZEDAGENT
2.1 Owner of Record: ':~72i'Z£Zm )/1[":." '-/. j'"'T';" n;7(?,'~~~ .
Name (Print) (A ",/V), ,L. ".,.."L"~-"';;'lfud ,J£rQ.IJii~ll~J:d,~Z:'l'i,/~}£~jJlc~, OIUPP
Current Mailing Address:
Signature~ j~~ r -k~. .w".:,2Lj.'jE'L::Z/!f6.~~:.w~",._~.'"
Telephone
2.2 Authorized Agent:
1 Name (Print) CU!!~I)!tJ.Ieili[1g )I,~~[e.,ss:.
Signature Telephone
SECTION 3 • ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be
completed by permit applicant
Official Use Only
1. Building
2. Electrical
, 3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6, Total = (1 + 2 + 3 + 4 + 5)
Building Permit Number
Signature:
,~-, "'-.-~,",~,, '"
(,?,]OQQ-
.:95uu
(a) Building Permit Fee
I (b) Estimated Total Cost of
Construction from (6)
's·'··::"'''-~·''·-·· ""~.=,.•. .", (J C .I Building Permit Fee
"" " ,,"X'''-~_ """,~. "h
.1;~/OOt.)· DO Check Number
F This Section For Official Use Onlv
Date
Issued
/f?,,7:J,
Building Commissionerllnspector of Buildings Date
.,
I
"-,,
$)Yw'
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL PEER REVIEW (780 CMR 110.11)
NoI=nnin",..rinn Structural Peer Review
.. ,'..~.<.~ ~...~ ~ "<v' "·"··"V' ~.....,. __~ ,." v _ ,.____~, .,~~ ~~'''·'''~~'~"A
I, 'D(~\& ~U\ljLL .-:\.~~rr~.6·\Wx~\.. ,asOwnerofthesubjectproperty
c c" '''''' -...'~' _ ...... " .,.:"••".-•••••,,~.'''•. ,,,....,,.....~.'•• ' .. "'0"'"."."...., ••• ........." • ';:;::.:.:;.:;:=' ,..,••"...., , ...".
hereby authorize ::fu~~j6 '*o~~'iC~.,.,.. ,. =:~.~.. ' L::-).. ,.. ~g\?. 'to
act/on .~u;ehaISin all;7Jelative to work authorized by this building permit application: ... " • _ / & '-/0""'" ~ , '( < l .._...Ld.""." ...... ""......" .....
Signature of Owner Date
I, ,·oo •. " ,."..,," "'" __ "'" " .............. ,."' ................., ...,."""•••• " ,as owne~~ev
~reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge~f.
Signed under the pains cmd penalties of pe~jury:
SECTION 12 -CONSTRUCTION SERVICES
ervisor: Not Applicable 0
Name of License Holder: . "0~~:: : 7\S"-CC(;::r'~"-"'". L;;: ..5 .... ,ex
License Number
\ \ D'<?0\~~=\"\-hIT XA·.:1&~~~b1~"'~~·;-"-C;I'i:'I~c)'\~'
Address . Expiration Date
._'~T< ,", ",'v' ">'_ N".
'-{\3:~t l{3'1'.'1
Signature Telephone
ON INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6»