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38A-116 � 411 ON ~*�� i~" '~^: " # xm 0 VILLAGE HILL - COACH HOUSE BP- 2010 -0214 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A - 116 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0214 Project # JS- 2010- 000266 Est. Cost: $178000.00 Fee: $1068.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MEADOWS CONSTRUCTION CO LLC 47301 Lot Size(sq. ft.): 38115.00 Owner: VILLAGE AT HOSPITAL HILL II LLC C/O COMMUNITY BUILDERS Zoning: PV(100) / /SG b Applicant: MEADOWS CONSTRUCTION CO LLC AT: ViLLA 7i= H!Li_ - tOACH HOUSE Applicant Address: Phone: Insurance: 166 MIDDLE RD (978) 465 -4735 WC BYFIELDMA01922 ISSUED ON:8/25/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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: 1 / b / C THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND ',.• IONS. _ S i nature: ,..k.. 40,4e# - Certificate of - �: s FeeType: Date Paid: Amount: Building 8/25/2009 0:00:00 $1068.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 6 To: ODORS CONSTRUCTION CO LLC: MI From: Anne Chandler 7 -21 -09 4:39am p. 2 of 2 ACCPRD CERTIFICATE OF LIABILITY INSURANCE 7l21;20Q9YY) PRODUCER CLIFFORD R LARSON INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 1343 MASSACHUSETTS AVENUE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ARLINGTON, MA 024764101 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (781) 646 9200 INSURERS AFFORDING COVERAGE NAIC # INSURED MEADOWS CONSTRUCTION CO LLC INSURER A LIBERTY MUTUAL GROUP 166 MIDDLE ROAD INSURER B: BYFIELD MA 01922 INSURER C: • INSURER C. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AOD'L P OLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSW) TYPF AF IN4URANr:F DA (MMIDDIYYYY1 DATE (MMIDD /YYYYI GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 7 POLICY JFCT 7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Par accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGO $ EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $ IOCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION WC2 352433 -038 9/12/2008 9/12/2009 T C WC L M(TS R AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 1 00000 OFFICER/MEMBER EXCLUDED? Y (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1 00000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The workers' compensation policy provides coverage only for the state of MA as noted in section 3A of the policy. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION HOSPITAL HILL DEVELOPMENT DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 7 DAYS WRITTEN CIO MASS DEVELOPMENT FINANCE AGENCY NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO S HALL 160 FEDERAL STREET IMPOSE NO OBUGATION OR LIABIUTY OF ANY KIND UPON THE INSURER. ITS AGENTS oR BOSTON MA 02110 REPRESENTATIVES_ • AUTHORIZED REPRESENTATIVE Jeff Eldridge J l C.3t.C,L$CSl ACORD 25 (2009101) ©1988.2009 ACORD CORPORATION. All rights reserved. CELT NC.: 5392588 CLIENT CODE: 13 Anne Chandler 7/21/2009 4:36:35 AM Page 1 00 1 A °RO® ) CERTIFICATE OF LIABILITY INSURANCE 8/19/2009 PRODUCER (617) 471 -1220 FAX: (617) 479 -5147 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Amity Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 500 Victory Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Marina Bay North Quincy MA 02171 INSURERS AFFORDING COVERAGE i NAIC # INSURED i _ INSURER A: Safety Insurance Co . Meadows Construction Company, LLC INSURER B Great American Insurance Co. 166 Middle Road INSURER C : Hermitage Insurance Co. INSURER D: Newbury MA 01922 y INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'U - - - - - -- ----- - -� - -- I 1 POLICY EFFECTIVE POLICY EXPIRATION T_ LTR porn] TYPE OF INSURANCE POLICY NUMBER , DATE (MM /DD/YYYYI + DATE (MM/DD/YYVYI ! LIMITS i I GENERAL LIABILITY 1 EACH OCCURRENCE $ 1, 000 000 " -"" DAMAGE TO RENTED - - _ I X I COMMERCIAL GENERAL LIABILITY 1iGL528016 -09 8/19/2009 8/19/2010 1 PREMISES (Ea occurrence )._ 1 $ .100, C X ; I I CLAIMS MADE X OCCUR ' !� �F MED EXP (Any one person) $ - -- 5,000 PERSONAL & ADV INJURY 1 $ 1 000,.000 1 ! GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS - COMP /OP AGG $ 2,000, 000 X 1 POLICY PE LOG 1-___----] I AUTOMOBILE LIABILITY 1 ANY AUTO I (CEaccidentSINGLE LIMIT $ 1,000,000 ; A I ALL OWNED AUTOS 2702831 6/30 6/30/2009 __ BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS I I BODILY INJURY - - i i --- (Per accident) X • NON -OWNED AUTOS Per accdent PROPERTY DAMAGE 1 (Per accident) $ GARAGE LIABILITY I AUTO ONLY _EA ACCIDENT I $ ; ANY AUTO EA ACC I $ OTHER THAN __.� I I AUTO ONLY: AGG ', $ X OCCUR CLAIMS MADE mbrella Polio # EACH OCCURRENCE $ T 5, 000, 000 - -- - . r /UMBRELLALIAB 8/19/2009 8/10/2010 1 AGGREGAT $ • 5, 000 000 Y — C o Be Assigned I _ _ $ X DEDUCTIBLE DEDUCTIBLE L_.____ _ $ _ X ' RETENTION $ 10, 000 $ WORKERS COMPENSATION WC ■ AND EMPLOYERS' LIABILITY , -1TOBY LIMITSL,__ _ ER. . STATU- 10TH-1 OFFICE In E.L. EACH ACCIDENT $ i AFYICE OPRIETOR EXCLUDED? I "- "— - -- - - - -" -- - - - -- - - ANY PROPRIETOR/PARTNER/EXECUTIVE (Mandatory $ It es, describe under ! y E 1. DISEASE - EA EMPLOYEE SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHERproperty & 'IIMP335144500 08/19/2009 08/19/2010 Installation $200,000 B Installation Floater in Transit - $50, 000 Any One Loss $200,000 I Limit ' Tsmr+ Lnratinn $50, 000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re: Village Hill, Northampton, Coach House Roof Replacement. Hospital Hill Development LLC and Massachusetts Development Finance Agency is included as Additional Insureds for General Liability and Excess (Umbrella) Liability as required by a signed written contract or agreement with the Named Insured per Form CG2033 Endorsement. Notice of Cancellation provision is 30 days except 10 days applies for non - payment of premium. Evidence of Insurance for work performed within the Insureds scope of normal business operations. CERTIFICATE HOLDER - CANCELLATION CKirby @Massdevelopment . com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Hospital Hill Development LLC DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN C/O Massachusetts Development Finance Age NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Connie Kirby IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 160 Federal Street Boston, MA 02110 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ Lisa Polito /LP t - ' ‹-_---- C-7-. - -e..� > ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (zoom) The ACORD name and logo are registered marks of ACORD • MASSDEVELOPMENT July 16, 2009 :EO Fe;.erai Street °OStc:,." asszc.;settt Michael D. Meadows 02,t0 Manager Meadows Construction Company LLC Tel. 61 7i2 v'00 166 Middle Road toc.,45.8D30 Byfield, MA 01922 ',x617 - 330.300: RE: NOTICE OF AWARD: Northampton Coach House Roof Repairs, Northampton, Massachusetts MDFA Contract Number: PO2037 www.m ssdp∎ettrrem ;ar Dear Mr. Meadows: Please be advised that your proposal for the Northampton Coach House Roof Repair Project in Northampton, Massachusetts has been accepted. Enclosed please find two copies of Hospital Hill Development LLC's Agreement Please sign aad return one (1) original copy of this Notice of Award and the two (2) copies of the Agreement Upon receipt of these documents, I will have the Agreement executed by Hospital Hi l and return a fully executed original to you. In addition, please begin assembling the required bonds (foam performance and payment bonds enclosed) and insurance forms listing Hospital Hill Development LLC, Massachusetts Development Finance Agency, and The Community Builders, Inc., as additional insureds to the policy. Please use the limits of insurance as indicated in the bid documents. Thank you. Z r_h erel)f, Connie irb Contracts Manager Notice of Award Received By: Meadows Construction Company LLC .� 1/ 1 / ? Michel D. lvle o Date The Commonwealth of Massachusetts �,.. Department of Industrial Accidents -- = Office of Investigations .1"; 600 Washin Street Boston, MA 02111 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): 4. I l and I 1. ❑ I am a employer with am a genera contractor an 6. ❑New construction employees (full and/or part- time).* have hired the sub contractors listed on the attached sheet. 7. El Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. 1] Demolition capacity. employees and have workers' working for me in any P tY• 9. 0 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions ❑ officers have exercised their 11. Plumbing repairs or additions 3. I am a homeowner doing all work ❑ myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my 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' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 i s true and correct. Sittnature: 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 #: • Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I , as Owner /Authorized 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 and penalties of perjury. Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : - .t i7 30 l..... tit Q` ( Mat5 7 5° 1 ' License Number M, t-c- _l .__ ....1'l o, 4 ..... ( L. I? � Ig. Rd ...Gyr.e.i 1)4.4.„ _.,.._,.& / !3 Z h !, Address °CQ?? Expiration Date Sign. ure Telephone SECTION 13 - 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 b ilding permit. Signed Affidavit Attached Yes No 0 i 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 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date „ Name ...,.m, _ � ®. v e Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor N Vet. t 75 Not Applicable ❑ Company Name: PI Responsible In Charge of Construction Address Signatur Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage P Setbacks Front Rear � _..... .�. Building Height Bldg. Square Footage Open Space Footage o (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO (3 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained (3 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Wilt 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. w , Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration 0 Existing Ground Sign 0 New Signs ❑ Roofing Er Change of Use ❑ Other ❑ Brief Description Enter a brief description here. - 4- S er 0 ( / R-s j'/ia« 5"Gi.iayie5 f Esc . Of Proposed Work: ma ', 4 c4 ‘ti414 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 0 A -2 ❑ A -3 0 IA I ❑ A -4 0 A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ' I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ j 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A 0 S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: R S Special Use ❑ Specify: ,. a... . ..e. , 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): _ ........._M_ _ ,... __._,. 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) 1 1 st 2nd 2 n e 3rd 3rd 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood ZoneD Municipal ❑ On site disposal system f" w ' Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit Building Department Curb-Cut/Driveway Permit a 212 Main Street Sewer /SepticAvaiiability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Otlser Specify° 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: This section to be completed by office Map Lot Unit Zone Overlay District ks\G • • Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: j o- 1 1-14i , J vel. p g , -,. . L L C, 1 � r 1 .. 5-6 n 1�1a.., Zr Ic� Name (Print) Current Mailing Address: ///�J ,U� A pho ../ 3 F q c../ 5t ret key4 1''l r r? / Signature ` `�' `2y� —( Telephone 2.2 Authorized A gent: Name (Print) Current Mailing Address: .1 ,„ '" Signature `� Telephone SECTION 3 T� IMATED CON RUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 6 006" (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing ; Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total - 4(1 +2 +3 +4 +5) C ���, -" Check Number /63i This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /inspector of Buildings Date I