35-115 (7) t'
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
THE MAS SACHUSETTS STATE BUILDING CODE
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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....... a -1Q0.......a
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New Construction a_Existing.Building.- q Repairs) ..c, Al . . C Addition fl
Accessory Bldg. a "Demolition C Others a 'Specify: '
Brief Description of Proposed Work ` _
`')1 c If.J �l�t �'- / v 1 I•^? ��LU_ Div f i� S Tf u CU
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Item . Estlma bed Cost(Dollars)
to be
completed.by permit applicant i
1. Building
:
2. Electrical
3. Plumbing
4. Mechanical WVAC)
5.Fire Protection
6. Total-i(l+2+3+4+5)
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I. as Owner of the subject property
hereby authorize to act on
my behalf,in all matters relative to work authorized by this building permit application.
3%wAture of Owner Date "
L AtvnertAzrthorized AgeAt
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 .q�at Date
672 780 CMR-Sixth Edition 2/7/97 (Effective 2/28/97)
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
Eq 1 t"j__ .
The Comusono 6alth of Massachusetts
State Board of Building Regulations and DEPARTMENT.Q_F r
Standards BUILDING INSPEGT(QI i'C 1 4. 2005
TOWN HALL.,
Massachusetts State Building Code 100 MIDDLE STREE
y$Q CMR HADLEY,MASSACHUSETT401'0310 j t
APPLICATION TO CONSTRUCT,REPAIR,'RENOVATE OR DEMOLISR A ONL OR TWO FAUMT DWELLING
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1.1 Property Address; 1.2 Assessors Map Jk Parcel Nuinber:
!i1 Map Number PamLNutaber
r
1.3 zoning Information: ' 1.4 Property Dimensional:
ZabUng Dbtrict Proposed Use- Ut Area hA PYoixtage(!t)
1.5 Building Setbacks i
IhontYard Side fards Rear Yard
Req wed Provided Pc4uired Provided. Required. Provided . .
1.6 Water Supply ac'Q.1 e.:40,•R 541. 1.771eod Zone-laformation: 1.8,Sewage Disposal System:
Public o Prtvate a Zone: • �Outside Flood Zone 0, Municipal a.On.site disposal:aystern 9,
2.1 owner of Recotd
CS'i. .0,-r J1/P-Ii 1= I 7�
Nasum {Pnatl Address for 3eMee:
Re/ J
SIC-t— Telephone
2.2 Anthorized Agent
Name(Print) r Address for SwAce: .
Slgpafuce Tede hone
3.1 Licensed Construction Soperrl"r.. Not Applicable a
Lioataed Construction Supervisor. License Number
Address Equ-Ation Date
Lure �leph�r>c
3.2 Rsgistered Some lmprovement Contractor. Not Appflcable.*. '
Company Name Regis' nation Number
PVK
Address Expiration Date
Telephone
9/19/97 OMetive 2/28/97}-corrected 790 CNM.Sixth Edition 671
14 DREWSEN DR ' BP-2005-0781
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 35- 115 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0781
Project# JS-2005-1088
Est.Cost: $4900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RONALD KEITH 102109
Lot Size(sa.ft.): 8102.16 Owner: WARE ROSEMARY
Zoning: SR Applicant. RONALD KEITH
AT. 14 DREWSEN DR
Applicant Address: Phone: Insurance:
5 BIRCH MEADOW DR (413) 584-5589
HADLEYMA01035 ISSUED ON:2114105 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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupangy Occupancy Signature:
FeeType• Date Paid: Amount:
Building 2/14/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo