36-006 (2) Vlll. ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
IX. SITE OR PLOT PLAN — For Applicant Use
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BOCA FORM APEBP — 669 C1969 BUILDING OFFICIALS & CODE ADMINISTRATORS INTERNATIONAL, INC.
IV. IDENTIFICATION — To be completed by all applicants
Name Mailing ad-ddrryess�— Number, street, city, and State ZIP code Tel. No.
Owner or
Lessee
Builder's
2. License No.
Contractor,4o*/
3.
Architect or
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to
make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction.
at re of apt ant Address Application date
2�A� s/ f v -is"- )1/
DO kJl T WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plan Review Date Plans Date Plans
Plans Review Required Check Fee Started By Approved By Notes
BUILDING $
PLUMBING $
MECHANICAL $
ELECTRICAL $
OTHER $
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit or Approval Check Obttaitn a d Number By Permit or Approval Check Obtt t ed Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issued l / 19�
Building 6- Fire Grading
Permit Fee $ Live Loading
Certificate of Occupancy $ Occupancy Load
pr d by:
Drain Tile $
,.A2r-e�000'
Plan Review Fee $
TITLE
i
NOTES and Data — (For department use)
a
' CITY OF NORTHAMPTON
OFFICE OF THE INSPECTOR OF BUILDINGS
212 MAIN STREET APPLICATION FOR
NORTHAMPTON, MA. 01060 s PLAN EXAMINATION AND
BUILDING PERMIT
IMPORTANT — Applicant to complete
yJall�items in sections: 1, 11, 111, IV,�and
(,�tIX. /,// O
1. AT (LOCATION) `� l ��"V '°•�� / "v DONIN CT'•'
LOCATION (NO.) (STREET)
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
SUBDIVISION LOT BLOCK LOT
SIZE
II. TYPE AND COST OF BUILDING — A11 applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m
M
1 ❑ New building Residential Nonresidential
2'4 Addition(If residential, enter number 12 One family 18 ❑ Amusement, recreational
of new housing units added, if any,
in Part D, 13) 13 ❑ Two or more family — Enter 19 ❑ Church, other religious
number of units— — — — -.
3 ❑ Alteration (See 2 above --)p. 20 Industrial
iq E] Transient hotel, motel, ❑
4 Repair, replacement 21 or dormitory — Enter number E] Parking garage
5 ❑ Wrecking (If multifamily residential, of units ——————— — -- 22 ❑ Service station, repair garage
enter number of units in building in 15 ❑ Garage 23 ❑ Hospital, institutional
Part D, 13)
16 Carport 24❑ Office, bank, professional
6 ❑ Moving (relocation)
7 ❑ Foundation only
17 ❑ Other — SpeciJy 25 ❑ Public utility
�� 26 ❑ School, library, other educational
B. OWNERSHIP "�/ G� ""'"'"`" 27 ❑ Stores, mercantile
8 Private (individual, corporation, 28 ❑ Tanks, towers
nonprofit institution, etc.) 29 ❑ Other — Specify
9 ❑ Public (Federal, State, or
local government)
C. COST (Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food
processing plant, machine shop, laundry building at hospital, elementary
10. Cost of improvement,,,,,,,,,,,,,,,, $ school, secondary school, college, parochial school, parking garage for.
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed, enter proposed use.
in the above cost
a. Electrical.....................
b. Plumbing .....................
c. Heating, air conditioning..........
d. Other (elevator, etc.)............ .,}
11. TOTAL COST OF IMPROVEMENT $ SZ�
111. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS
30❑ Masonr y (wall bearing) 40 F-1 Public or private company 48• Number of stories................
31 Wood frame 41 N Private (septic tank, etc.) 49. Total square feet of floor area,
all floors, based on exterior
32 ❑ Structural steel dimensions .....................
33 ❑ Reinforced concrete H. TYPE OF WATER SUPPLY
34 ❑ Other — SpeciJy 42 X Public or private company
50. Total land area, sq. ft. ...........
43 ❑ Private (well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
F. PRINCIPAL TYPE OF HEATING FUEL TYPE OF MECHANICAL 51. Enclosed .......................
35 Gas Wi ere be central air 52. Outdoors........................
36 Oil conditio ' ? .-✓�
❑ / ❑ L. RESIDENTIAL BUILDINGS ONLY
37 ❑ Electricity 44 Yes/ No 53. Number of bedrooms..............
38 ❑ Coal �/39❑ Other — Specify Wi ere be an ele�45
54. Number of Full..........
46 Yes 47❑ No bathrooms Partial........
I hereby certify that the proposed work is authorized by the owner of'reord
and I have been authorized by the owner to make this application as° his
authorized agent.
SIGNATURE 0' AGENT
ADDRESS
(NUMBER) (STREET) (CITY)
APPROVED BY TITLE
DATE 19
. T
DEPT. PILE COPY
ZO
DEP.AR Y' NT OF BUILDING INSPECTIONS BUILDING O a
212 MAIN STREET
NORTHAMPTON, MA, o1o60 PERMIT VALIDATION
36 6 CODE # 79
DATE n(toher 19, 19-79 PERMIT NO. 595
APPLICANT Regina M- Ryni-,h,ra:y ADDRESS 28 Forest Glen Dr.
(N0.) (STREET) (CONTR'S LICENSE)
PERMIT TO CYi]mttey & stove ( 1 ) STORY For wood bumin.g stove NUMBER OF 1
DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION) 28 Fbrest Glen Drive -ZONING URA DISTRICT
(NO.) (STREET)
r BETWEEN AND
o (CROSS STREET) (CROSS STREET)
A
LOT
m
SUBDIVISION LOT BLOCK SIZE
O
O BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
10
O
Z TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
0:
IL REMARKS: T-nst-9,11atinn of metal bestos c4i=ev & wood—burning stove
0�'
AREA OR t PER MIT
VOLUME ESTIMATED COST $ 4.5o.00 FEE
(CUBIC/SQUARE FEET)
OWNER rPhnmaa T & Regina M. Brushway
/ BU
ADDRESS 22 yoT en7F Gj an T1aj Z7P? Fq nra_ n_nin. Ms- 01060 B
(Affidavit on reverse side of application to be completed by authorized agent of owner)