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32C-121 (8) 4 .$1iAMp�, . . d s g,, , :� a Q xf r of Nort1ia ttptort • 1- --u _ �r''�/.°1"�� 'Massachusetts t %,dam_ �)N P. '- `. ' DEPARTMENT OF BUILDING INSPECTIONS '� _t3_--/_ INSPECTOR 212 Main Street • Municipal Building ,-._..-5‘.,, Northampton, MA 01060 1 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction super.•;sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing &gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location ., • a. "'" , ..,vuo-fp2.. • .!k 40.4.t,•I't fift 4 (iitir of Northampton ,-, ,-- {-,--------*---- -.'E" ....- _: l ., .,./ ... . 4(.4f -...:. =---: -,,..... DEP/u2TMENrf OF BiJILDING INSPECTIONS • s-----P I__....= 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKERS COMPENSATION INSUIZA.NCE A.171.11J)AVI.T .. . . .04 . I (Ilc-ens.-ic,tx.-7niltte.fi) with a principal place of business/residence at: /(579 5:P/-/;-, / 1/o-re xt!e (phone:1. 5-6-Z- "-c3 YtY / (strectici ty/-..; licii-ip) do hereby certify, inici:er the pains - and penalties of perjury, that: _.. ( ) I am an employer providing the follo\vinc:. ..-,.orker's compensation covera4e, for my employees working on this job: - (Losurana.- Company) (Pciic-f Narnbcr) (Expiration Date) ( ) I am a sole proprietor, (2.enerai conn-acT.or or homeowner (circle one) and have hired the contractors listed below who have the follov-iing, workers compensation poilc:es: (Nkunc of Contractor) ansurancc Coirit-ya:lToticy l\Ztunbcr) (E..:Kplmtion Date) (Name of Contractor) (Laslira.ricz Co.tritianyt?enc-,, Nurfo,r:r) (17,N.r.iiration Date) — (Name of Contractor) (Insurance Comp: NvPo I ic-,y Nrunber) 1,Fxrrat:on Date) (Name of Contractor) (In.suanc-:.... Comtx_--,y/Policy Numr) (ENDI.:-.1tion Date) (atu,cli t.nditioo..1 nre 5r,!...:cn.:-......,,: ,,;:lf.'r.,:,,,:c.,c..--•.:.•:,..;-. .jj,,,----.--•.,—) KI am a sole proptieior and have no one -:,vork.in for me. ( ) I am a home owner- 1)er:el-mil-IL; all the vs,,:-: nivscli: NOTE:71cz..sc bc asVatt Illal W11:30 li(!1- 0,11),71:1‘.N',.-,a cp1:7y-0,7:-..-7.7-to c'.)trxit,..--.2...atico.0-,:t,"-tr-:c--'''''''c4""--P'uir''''':''' flOt I)CC th.ta throo uniLl ir..1,c-Lr.di',.!-)4 rv.c...vu-r.r r=:,3.7.7 OC 00:••■,.ET,'-::-:=-1 24,2'..rtZr..!-.1"It thCC!..0..72 0,...< employers• under the wez-kee:r. r.r------...=r-ticc,....c:(GLI52-1-2 I.(5)).‘-i,17.1.'-:-2-.•,0,1.0y t hotocoo-ocr for t br=t5c cc prrnu::-..,t,r.--r.enrc thc legit ctsoar of r...o anuployar cod-et ti.lt W o.rkce:C-ocopor--ation:'..ct_ I u.n.cierat,uact that a copy of this ruay br foc.va.,..1,..i to t.b,1.),partalcra of loaustrir.i Arci,.....-tt.?Of no.,of ":4 for the coverage vai.E ..tioct ttod that failure to f,..:C.11r-co,..erage ur..thr:ccr.icc 25A of 2'.f.G1.152 can Icati to the impositicci cfcr:::.'ir.cti per- cs coce.L.ctg of a fine of op to S1,50,0.00 no:.'..'c p -K-ri of o7 to or...}-:-.:.1!..7.i civil pcn2.1ti c.1 in'.I 4:bon of a Sto?Work.01,1^..:tr,t1 r lint ot S 100.0Q a thy agliir.t ay.:. For(.5,43a:tuyaral we only i , il Pcr mit Ntunl-nr _.___ 1 ,,,-- c.,nature of I.iccIt!;cfill)crot l'-tc'; ---7)..,-,-:•.- c. c -L . w . . SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Superviso Not Applicable Name of License Holder : f^G'� CXU✓ ©i7/0 99..E License N mbe / /,,/ ` pr/w 1 Firekvc c / /a 0.y Address (4,L•// Exp. do ate ‘"`0 9/8 4/) 4I O4 Signature Telephone w.Re_ .e-:6111'1Threarrrprove Contractef -_;7 �i - . Not Applicable.0 ' / 0/ SiIU-crr n v (.4 r /0 Wee? Company Nam r / Registr ion mber /8, ,spr/ /-� ji recce 7 / y a / Address Exp.ration Date Telephone O 9/kg SECTI010 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 tl'C No ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • p YY ,i' n� - .ro2ir ° .:, p x2' 3p r" *i SECTfONt5 DE RE ON OF'PROPOSEb WORK(check=.a�I ap lira'ile n P �'c, '. New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ • Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work:* e Y 1e'A1 j,.M.r //Ae "irk. C4//91;17 //fact" Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll❑ • Sheet❑ 6131fINEMore ndto `dd;itin to existink_h ifi—; cam3ple: e:the;fio.Ll,o MI: 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. dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply S,EC7IUTat 1 0 VNER iU1 HORIZAT�ION TO BE COMPLETED WIiEN; iOWNER-AGENTia O► TRACTOR ter_, APPLIES FOR BUILDING PERMIT DAB as Owner of the subject property hereby authoriz f2.vd're�.t� iu "Ci' to act on my behalf, in I maters relative to wo l autD.orrized by this building permit application. 1/Z Signature of Own- Date n 1, i Sreg1 l 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. /19V1kikre-a2 CA 14 rC7-ki Print Na e • • 9/8 LPS Signature of Owner/Agent Date Section 4. - ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _ Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (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 J/� DON'T 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 # B. Does the site contain a brook, body of water or wetlands? NO tV DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO X IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: _.. . ._ ....- w City of Northampton Building Department a g' ,,zf ik`v" _.�__ 212 Main Street t og i6 q Room 100 e� f.Arif i.�l Northampton, MA 01060 4 6r F � max, phone 413.587-1240 Fax 413-587-1272 -� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION , This ectionrto`b ,completed by.office. 1.1 Property Address: �; `` ` . z 1 l r " d4 /-r MapA � �� ,t ;,� 4701-7—h 11✓Y1 fr,z iZone Overla®a. ri U 4 EIm St�District ' k .40& 7 cptpistrict _..°? SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED-AGENT 2.1 Owner of Record: .... . _ `mac f-F ,re)vd �-\ •moo 4rTay/ Name Current Mailing Address: ¢ � mil sj ) `lq Le till x �^- Telephone Signa (/ 2.2 Authorized Agent: _ / /Q're 1 (% fc� /6;4./ t.Sf'f-/i/vc sr F -eE ''e. Name(P . C1-/A-At! Current Mailing Address: y ,.5-676-09r8 re// y�7- e" 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 2. Electrical (b) =Estimated Total Cost of - Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) �f y I5. Fire Protection ,/ `` ee, 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 09,-0 0 This Section For Official Use Only Building-Permit-Number: Date Issued: Signature: 1 Building Commissioner/Inspector of Buildings Date 151"111.0 o $ Tit 7 of N4rt1 &mp tm )L == _ /, c�{. r•i _-- 1,: y11 855ACh1iStttS '_VI .y DEPARTMENT OF BUILDING INSPECTIONS ^4,-7 _.= f_= /? INSPECTOR 212 Main Street • Municipal Building %,,4, ,,., Northampton,MA 01060 . r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups:,•i sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, k\ ,f � Cs understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date t 0/7-3/05 Address of work Z location ,1, - S - 4D r\-/tA„..,,,..„(}10 A 1,46 l . - • ‘ .2•...)- - -clt.id-1.1'2- „. -.<:) . 04. • -s- I ) 1 t •jr 4 4..... a_t fik 4 Olitir of SX11-triliampion ,--, _--.--...-_g--q. : --,--...... r— J..1Alszaciinsct15. , .<.,...,•'4d%2:r....c,' _......,M.....10.— DEPARTMENT OF BiJILDIJG INSPECTIONS 212 Main Street ' Municipal Building ., Northampton, Mass. 01060 WORKER'S CONIT'ENSA'I'ION INSURANCE AFFIDAVIT I — --- (11CCP.ftC,ipOrin;tic ) with a principal place of business/residence at: -------- -------- ____ _ (shonei:) (stl-c,...-Lici ty/s-,ale../7,p) do hereby certify, under Lite pains and penalties of perjury, :hai ( ) I am an employer providing the fancy:inc. worker's compensaucn (.:.ovel-a'..,.e, for my employees working on this job: - (Lasusance Company) (1)clic-f Number) (F._.x-pirtiLion Date) ( ) I am a sole proprietor, g.e.neral contractor or homeowner (circle one) and have 'aired the contractors listed below who have the follo-wincz workers ea:irons:at:on policies: (Name of Contractor) (insurance Corripao-Ti/Polic.-.-T. Number) CExpirataon. Date) (Name of Contractor) (Insurance Co=anviPoiicy Number) (Expiration Date) (Name of Contractor) (Ins-urancc CfrinpanyiPolicy Number) iExp:ration Date) (Name of Contractor) (Insurance. Co mr-any/Poticy Number) (Expiration Date) (,,ti..-,..h..6-..heic.-,..1 s!,..,-_-t i.F::,...:,,,,,.-..-..:-, -,..:::.,,..::-...---.,..::c.,-.;- :: -.: n ii C•:<:',-.7..7::,'- ( ) I C a dole proptatt_or tt:id haw,' no 011:-_,‘ -•,,,•cii.-kini?, for me. ( am a home owner Dcrfo7.-ininq all the -\.,,,,-;•,-k ,,, self NOTE:pICZSC bc aw-J.,-..:thz:..0,-;:..i.ic iii.:740,A1X71-3‘kirD C":7:1)I ClY P.:7,-----7*LO('.):::',..1.:,f..—.13..00c,Cs."::::41-.1 i CO CS:7:pair w,,ai,:.,.7:-,:.,:wci:::::: not more then throe unity tr.triton the hi,:ii.rseowtsr.-rre or pc il'ie:cr.;..t.-.^...3 z.7:,..1.rtr.r..!..r.:111 -cto err n..:‹ccncrally 0:.0.:: ::::: '---=?Ic'Y' '.3 u-r,dcr tit V:' ,:i',l'..,MTZ-,, ::CCI AC:(G 1_,I f,2 :::1(5)),r.c.s.T..:: o-,-:hy e hotntotvr■cr for e 1..cc-IL:c o.:pnrmi::-1.7.:,..7.-.--.',.,:r,:c 1::::. legal status of rua anaployar under ttio Wcvkces 1 un-cicrItantcl that..copy of this rt.tcr....r...:ry....y bo for-,,,,r,1,,,i to 11,,,,D D-f../xut..-1,4.-ris.of Lnau.stril.1 Accie....,-213 Ofric.s of in,■rselt.ie for tlx covcrxgc vcrifi ....tion And thm.Eilurc to ::::covtr:47.ur.d..7:-scc.....ic.-a 25.A of MOL.152 can lcui to te impositim of cr....-7.int.1 per..ahcs opcnisting of&fine()flip to S I,5DO.00¢11.f..."(1"ir:::pri.7.--x-zr,:ni of up to cra yz,..1-tr.1 civil perultic3 in'.4,c f,,-in off,.Ste:,Wc-rir-07\11=7"!Ind t Eris of 1-100.0.0 I thy IF,.....ixra ra-... _.... .. - . . / "' ''' / Pcrrnit NumY-r ____ tyrapg ___IA)t __ __ -- ..._ ... far!,-,0 " .rrnil.te ... . •—ri■••:•':- ; SECTIONS CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 7".f eie : 'titil&frife rac c`y ' ,F y' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECT,CON 10 WORKERS' COMPENSATION-INSURANCE:AFFIDAVIT(MeG.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 ❑. ® 0M ,x. WAYA ;, ' tin The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official, on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" - es and assumes resp•• '.i ity for compliance with the State Building Code,City of Northampton Ordinances, Stag and LI cal Zoning La and S 'Ste of Massachusetts General Laws Annotated. Homeowner Signature %- Aar _ I - • SECT,IO� D P,TddONEO'r'P4ROPOSED WORK(check,a1I=-applicable) ,".•': ::.m.. -sue : .t ter.. gym-.. .y1: a ik,:i-sg',.,..... ;,, .... W,- f New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Er Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks[ ]] Siding[ ] Other [ ] Brief Description of Proposed Work: Cz t1A.c, Old Sh;ry tQ5 t' f I�tce.. t4J.' i�t.,,,,i sJ )Li Alteration of existing bedroom Yes `�No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes Plans Attached Roll 0- Sheet 0 aa ; . ou .:::&,:til®" ITMair il f aisti iZari g fifer t rrati e e he fol .o thl. 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. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes Nc j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No I. Septic Tank City Sewer Private well City water Supply SEC OIPI` Y 1 -Rf1I T.HORIZATION TO BE COMPLETED WHEN OW1YAFSAWEN 000NTRWCTOR APPLIES FOR BUILDING PERMIT 1. cCr , as Owner of the subject property hereby authorize -t'.i" r^^ to act or my behalf, in all m. - - . 've to w. •'authorize' by this building permit application. ✓. VP' le to/Z3f05 Signature of Owner r��,�' Dat J 1, v f Dc,„ v\ , as Owner/Authorized Agent hereby declare that the statements Ind information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the ns ed penalties of p- -ury. Print Name Signature of Owner/Agent / '. D to Section 4. - ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear • Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding eve een issued for/on the site? NO DON'T 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 # B. 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: C. Do any signs exist on the property? YES NO 17 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: ... . .... ............. . City of Northampton Butldtng Department I,� 1: 212 Main Streeta � < � �' • Room 100 Northampton, MA 01060 - pine 413.5 8-7-1240 Fax 413-587.1272 APiiii ATiO?l cofNSTRUC1, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION J • This sec o to bele6ii erect„byofficec 1.1 Property Address: �/�J�1 � ap snit "V Fri■ S s M � ,�a ...:. ```‘.:441k Ovg r Zone Overlay ® str Elm„St p�strict` = CB'D�snct . SECTION 2 - PROPERTY OWNERSHIP.,/AUTHORIZED'AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: `_ ;� Telephone Signature 2.2 Aut,'rized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION,'3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only' completed by permit applicant 1. Building S- (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 =(1 + 2 + 3 + 4 + 5) Check Number 96-- This Section For Official Use Only Building Permit-Number: Date Issued: • Signature: Building Commissioner/inspector of Buildings Date • vas : COMMON`S LA:LTH OF MASSAC d USE'S TS Map:Block: 32C- 121 CTFY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0356 Project# 3S-2004-0512 Est.Cost: $4300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Andrew Church 104480 Lot Size(sq.ft.): 10497.96 Owner: DAW JEFF Zoning:URC Applicant: Andrew Church AT: 20 FRUIT ST Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON:9/30/03 0:00:00 TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY TO ROOF & LINE SUPAFLU CHIMNEY LINER 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: l© -a 0 -O3 THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATIO OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu•anc d% si•nature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 9/30/03 0:00:00 2260 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo