66 Emily Ln - building permit applicationSECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Department use only
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City of Northampton
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Status of Permit:
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Building Department
212 Main Street
Curb CuttDriveway Permit
Sewer/Septic Availability
Signature
Room 100
WAG I vD � �ATe E'r. Ny I� *A44MfTtl l
WaterMell Availability
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Signature' " Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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Northampton, MA 01060
Estimated Cost (Dollars) to be
Two Sets of Structural Plans
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phone 413-587-1240 Fax 413-587-1272
Plot/Site Plans
pt (aI 5 'w�
(a) Building Permit Fee
2. Electrical
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(b) Estimated Total Cost of
Other Specify.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE
OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
(0 /_ J;ft'/ f Map Lot Unit
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�10P • _ Zone Overlay District
4A PT I�/t
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S44truet, d &Ppkw Vora (�DiE N'(; t+r 610 �Awj t N, [VbP'7NtA/KPTUN
Name(Print) Current Mailing Addr ss:
y— if I G to ee,- WY
Telephone
Signature
2.2 Authorized Agent:
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Name (Print) Current Mailing Address:
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Signature' " Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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1 t tf %Pw X OL. S9/0'/66 0 0 s , _ 7 01^
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by permit applicant
1. Building
pt (aI 5 'w�
(a) Building Permit Fee
2. Electrical
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(b) Estimated Total Cost of
Construction from 6
3. Plumbing
I
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5)
Check Number
This Section For Official Use Only
Building Permit Number:
Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
'A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW a YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry
of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conserv
ation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES O NO
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
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 O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
'E' Tm i N i n'b V'/D(f
All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Section 4. ZONING
Existing
Proposed
Required by Zoning
This column to be filled Zy
Building Departmen
Lot Size
Frontage
Setbacks Front
Side
Rear
L: R:
L
Building Height
Bldg, Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parkiniz S a
Fill:
ume & Location
'A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW a YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry
of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conserv
ation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES O NO
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
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 O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑
Addition ❑
ReplacementWindows Alterations) Roofing ❑
4AfBeem �f
Accessory Bldg. ❑
Demolition ❑
New Signs [O] Decks [M Siding [0)
,OOthhee,r,[[CQ
E Description of Proposed (�12 '(a V 4(�� ] SAvm r �
Brief De/&Oeme Q• +' % cj/*XI
�W�
�s�4::m(Aof4 P;sFw % 4 Ait- �nfh Lr J
Work: i0 i� rAtiCNA0AL. CA GF
I
Alteration of existing bedroom Yes No Adding new bedroom Yes ZN< No
_X_
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. Dimension
e. Number of stories?
f. Method of heating? Fir ces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L Is construction within 100 ft. of w nds? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or c r floor below finished grade
k. Will building orm to the Building and Zoning regulations? Yes No .
I. Se ank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION =TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, J 4 MAZ)O V0 Q"' SC IJ gkeLL
as Owner of the subject
property
Q
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hereby authorize f r► 1
to act on my behalf, in all matters relative to work authorized by this building permit application.
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Signature of bwnerDale
l
Owner/Authorized
as
A ent hereby declare that the statements and information on the foregoing application are true and accurate, to the best o m' yy cn�Wl€age
-and b lief.
Signed under the pains and penalties of perjury.
Print Name
Signature of wner/Agent Date
SECTION 8 =CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: L rl Not Applicable ❑
Name of License Holder: ��^t0 !'(''� �1�1 MFWGw 0�?14(.
License Number
Address Expiration Dale
Signature Telephone
9. Registered Home Improveme t Contractor: Not Applicable ❑
(Pie 07r tr &Ni Ub2 PS Iy IGS(o
Company Name Registra ion Number
RTWAPY�N, MA' 6%V)S))�b
Address Expiration Date
TelephoneE413- dab
SECTION 10 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(8))
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.
Affidavit Attached Yes....... 15( No...... ❑