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06-064 (5) OAK E XCLUD , AREA ACR E, S ® GA�c nJ .5.1 vv 15 b ---- G \\ . f-- �P t a c IRON r 9 -,nC .. 3 etback \ ' l 12 r FUTURE 1 , GARAGE ; � LUsi E 1 EX 170 Setback SIVE UNIT EXCLU i 2014-08-04 10:56 DPW Central 14135871576 » 14135871272 P 213 MUNICIPAL WATER AVAILABILITY APPLICATION Northampton Water Department 237 Prospect St. Northampton, MA 01060 587-1097 A Department of Public Works Trench Permit shall be required prior to any construction or connection activity associated with this application. Location: 70 Chestnut Ave,Extensions Lot 12 Leeds,MA Inquiry Made By: Jeffrey Morin 413-374-7799 Date of Inquiry; 7/soila Number of Type of Single Family X Type of Private X Units: I Unit(s): Apart. Comm Ownership: Condo Multi-family Rental 1Annlicant to fill out the ahnvel Municipal Water Main in Existing service to Front of Location? Yes: No; X site? Yes:X No Size of Water Main: 8" Material: Ductile Iron Age: 2047 Approximate Static Street Flow Test Conducted: Yes; No;X Pressure: 60psi If done attach results Size of Service Connection Suggested Meter Size: 5�8" Comments: The Water Department cannot guarantee adequate water pressure during peak demand times at elevations above 320 feet. • A corresponding water entrance fee shall be paid prior to making any connection to the municipal water system. • Arrangements of such installation shall be made with the Northampton Water Department with a minimum *Nuttelman, days notification, conform to Northampton Water Department specifications, r uperintendent of Water Dept, Water Entry$ 200 Meter$ 100 Radio$ 100 cc: Ned Huntley,Director Note: If this availability is for a new construction it must be hand delivered to the Building O Inspector. j u F $ � _ �Iassarl��rssffs DEPARTMENT OF BUILDING INSPECTIONS � 212 M�un Street 0 -Municipal Building ;INSPECTOR SV•y, Northampton,NLA 01064 LOCATION i SQUARE FOOTAGE AMOUNT BASEMENT @ .20 1sT FLOOR @.50 , ND FLR @3O Vz FLOORS, FINISH ATTIC,GARAGE @.20 DECK/PORCHES @ :20 TOTAL. ti . 6, 4� / 4� LL I Permit No. D03-15 Conditions: Driveway Permit } In lieu of plan approved by the City Engineer I agree to the following added conditions: 1. I will contact the Department of Public Works and have an inspector check and approve the graded gravel base prior to paving to insure compliance with slope and location; 2. I further agree that if in the inspections, any of the permit conditions are not met that I will at no expense to the City remove and replace the driveway as directed by the City Engineer. By: oner Signature Name: Jeffrey Morin Address: 29 Grant Avenue Northampton, MA 01060 Note: The Public Works Department recommends that you provide a plan showing the proposed driveway with grades and location in the future to avoid possible expense which you will incur by not getting approval of actual plans in advance. For Commercial and Industrial applicants, a plan showing the proposed driveway with grades, location and Planning Board permits are required. Cc: Building Inspector r Permit No. D03-15 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 7/28/14 Check#: 1037 FEE: $250.00 THE BOARD OF PUBLIC WORKS Driveway must be staked and house & lot number posted The undersigned respectfully petitions your honorable body for: A new curbcut Permission to install a driveway at: 70 CHESTNUT AVE EXT, LOT 5t Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All Drainage shall be directed off the driveway surface to adjacent land and not on the existing Roadway. Driveway surface to be paved as soon as possible if the grade of the proposed Driveway exceeds 3% or more. Homeowners will be held responsible for any cost to the City of Northampton in the event of a washout of this driveway. Code of Ordinances §350-8 8 providing standards for private, individual driveways as amended by the City Council on October 15, 2009, must be followed. By: Jeffrey Morin Telephone: 413-374-7799 ature: Proposed Location Inspection 4 P Gravel Base Grade Inspected By: Final Approval: _ THE BOARD OF PUBLIC WORKS voted that petition be granted. Edward S. Huntley, P.E. Director of Public Works Cc: Building Inspector (SUBJECT TO ATTACHED CONDITIONS 1 & 2) Z HIS & July 22,2014 HERS t Preliminary HERS Rating Confirmation Dear Building Inspector, This note affirms that the new construction project listed below has passed the Stretch Code performance and 2009 IECC&2012 IECC mandatory requirements for the pre-construction phase.This was determined with a 'preliminary HERS Rating'completed with the specifications and building plans presented by the builder. Midpoint inspections and a final'confirmed HERS Rating'will be completed and results submitted to your office. Builder: Neil Homestead/Jeff Morin Project address: Beaver Brook Development,lot 12 Chestnut Ave Extension Leeds,M A 01053 Preliminary HERS index: 57 Please contact me with any question. Thank you, Adin Maynard Certified HERS Rater Rater ID#: ERM_022 RESNET Provider:Energy Raters of Mass(ERM) 3.Sbf!,:WAior"rom Now"Ouso Ad0fic, Re�1ac� 4 sda rs iKf �.! ►fir Ica ' c ry Now Ana IL-31 Docks Z112 test fot a F�' _ WCI*I- Meratom of exwxV bedroom Yes NO Addsng new bedroom Y , So Altactvd Naffatwe in umfi ishod k l `try , 1f Now hono and w i d_dM*p to existing housing. in s. USt ot by Ems ____ 7wo Famiy Otter 4 ta, s fwnify unit m. N or 0 sathmoms � � ✓� 4d �f ..gg +may (� r� �.w #�.,y� Number�y .. a R 3 S'�: w :.al.M+�k � Aac'a F+3�: of < h„ T co f 1 i"l 3 * 00 t of well rK10 __ 'Y No, fs comMitlX1.4ft*ftr,100 Y k; 9 Goa , r t t ye I c T C 's _'X — Prwate well -.�«..�5 C41Y walpr Suppov _ SECT"U-OWNER AUTHORIZAUM F TO BE COMP'L y D WHEN OWNERS AGENT OR CY00t,LIES FOR IltRLDING PERWI p ° �iy�� �► iar+� AW111terety'� p � � M 3 info°t'S�$Pon ter'€she " [!Cb° art MM ry -=r, 'D`v M i'-q t*-or _ aft of a City of Northampton Statali Of Pw"%tl Budding Department curb ctww""voy pofftt 212 main strem ,, A ". * Room 1 WIMa ;A Northampton, MA 01 Two Seft a phone 41 a-"7-1240 Fax 413-587-1272 s"Ofy- APPLICATM TO CONSTRUCT,ALTER.REPAIR.RENOVATE OR OEMOUS"A ONE Olt TWO FAWL'OWELUWG SWIM I- yµ 3E�C CAE PRI T Rs$WI AGENT COSTS Dries i "maw Cost(c t ) be Use Orty tr rat� #�crrt t Fie ' ito Co nstr #�€ _, . Fire Prcftctvn TkIa f)f 0*WW Bu4dwg Date Issued, Daft City of Northampton " Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. 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 understand the above. (Home owner/resident's signature requesting exemption) will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street iD Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t'-7:-_V� C:1 OVlc92 rl1 Address: cl_24,E '4-�t=-- City/State/Zip: lVe, / Phone #: y/ `> Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors _ 2.5]_I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' 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. tContractors 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: ppl?Er Y� /�✓�5��`t- S C` C1 — Policy#or Self-ins. Lie.#: i P/�/�����i `� I Expiration Date: r 2-1- , / -Job Site Address: � i � ` �?`1'' City/State/Zip: tae-J-1 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 lo $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 ains and enalties of perjury that the information provided above is true and correct. Si mature: Date: Phone# ` y —-- --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#: J SECTION 8 CONSTRUCTION.SERU - ICES, •r 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Al License Number .-C1 4-LC— Al -L, - Address Expiration Date Si Telephone 9.-Registered Home Improvement Contractor:_ . ,_u_!�. _; „_. ,__,.,; Not Applicable ❑ Compa v a(rd Registration Number r - ?- ' r -V Address % Expiration Date --- =--�ry'!�( l�z T�2��n.i /)/✓.{- Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAUI7 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....... k No...... ❑ 11.' Home, wner Exemption 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demoliti ❑ New Signs [o] Decks Siding[O] Other[p] CX Brief Description of Proposed /(� ✓ :,U r..f S��� � Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet tia. if'Ne�ni house and or addition toexistihg housing, complete thefollowng; a. Use of building: One Family _ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms 2,/2. c. Is there a garage attached? 'VIO i r' r,� J d. Proposed Square footage of new construction. 2_1 1 6 Dimensions e. Number of stories? f. Method of heating? 'm l 144 ," / � Fireplaces or Woodstoves 04/0 Number of each g. Energy Conservation Compliance. Masscheck 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 _ _:SECTION 7a-.OWNER AUTHORIZATION-TO BE.COMPLETED WHEN :'OWNERS'AGENT-OR4 CONTRACTOR!APPLIES FOR�BUILDING PERMIT 4 /Z L as Owner of the subject property r hereby authorize .J F1�E 7 A-Z to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1z, .7 ' Aq 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 weer/Ag Date J . Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by'Loning This column to be filled in by Building Department j. Lot Size Frontage E Setbacks Front Side L:_-- R: L:'�_. R:+ I! e —J Rear Building Height t— j Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces I i Fill: __-_-_-- i (volume&Location) 1 1------A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW 1Z YES Q IF YES, date issued:° IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW Q YES 0 IF YES: enter Book ; Page( and/or Document#l f B. Does the site contain a brook, body of water or wetlands? NO 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 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 NO IF YES, describe size, type and location: R 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only ,City of Northampton status of Kermit 1 Building Department Curb Cut/Dnveway Permit. 212 Main Street Sewer/Septic Availability'!, vailability! oe '1 Room 100 Wat6r/1Nell Availability' Eiectr�c Plu „Ncathampton, MA 01060 Two Sets of Structural Plans * - =—` ph e 413-587-1240 Fax 413-587-1272 Plot/Site Plans';' fr w Other.Speclfy APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: / / r d C�t S��v 7 ✓C�►✓C_ C ��'d l/ Map L Unit c f I l!'Zonei, verlay District _EIm.St,_D!strict D�stnct- SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: AIR Name(Pant) Current Mailing Address: V-4 2-210'11 D i Te ephone _ Signature J �� 2.2 Authorized Aqent: 411 PLC 7 114 d 017- Cr��f�7- .4uv N��= /V• �v-V ✓Lt¢ Name(Print) Current Mailing Address: Signature Telephone SECTION -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use?Dnly completed b permit applicant = 1. Building} (a)"Building Permit Fee 2. Electrical �"S � (b) Estimated Total Cost of i Construction 3. Plumbing /�/ c1�Ji Building-Permit Fee _ 4. Mechanical(HVAC) Z 5. Fire Protection d U J 6. Total=0 +2+3+4+5) r�d(� Check Number Q - • This Section For Official Use Oni 41-7:- Date Building Permit Number Issued: Building Commissioner/Inspector of'Buildings Date File#BP-2015-0119 ' APPLICANT/CONTACT PERSON JEFFREY MORIN �e2e RANT AVE NORTHAMPTON 413)374-7799 Q p ADDRESS/PHONE 29 G ( PROPERTY LOCATIONCH STNUT AV EXT iDnt4l,'- MAP 06 PARCEL 064 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 2 STORY SFH W/DECK New Construction Non Structural interior renovations Addition to Existing AccessoTy Structure Buildinp,Plans Included: Owner/Statement or License 97133 /Q c (����+ 3 sets of Plans/Plot Plan t�.... ll 6 THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFPRMATION PRESENTED: /Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management 1' ' n elay Si re of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 70 CHESTNUT AV EXT-LOT 12 BP-2015-0119 GIs#: COMMONWEALTH OF MASSACHUSETTS MapBlock: 06-064 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:New Single Family House BUILDING PERMIT Permit# BP-2015-0119 Project# JS-2015-000217 Est. Cost: $320000.00 Fee: $939.80 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JEFFREY MORIN 97133 Lot Size(sq. ft.): Owner: IMRE LUDWIG Zoning: Applicant: JEFFREY MORIN AT. 70 CHESTNUT AV EXT - LOT 12 Applicant Address: Phone: Insurance: 29 GRANT AVE (413) 374-7799 O NORTHAMPTONMA01060 ISSUED ON.911512014 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT 2 STORY SFH W/DECK 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 Si nature: FeeType• Date Paid: Amount: Building 9/15/2014 0:00:00 $939.80 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 2014-08-04 10:57 DPW Central 14135871576 >> 14135871272 P 3/3 MUNNIrAL tftV _K!AVAILAbIL1 I T ArrLILA I IUN Northampton Streets Department 125 Locust Street Northampton, MA 01060 587-1570 A Department of Public Works Trench Permit and Sewer Entry Permit shall be required prior to any construction or connection activity associated with this application. Location: 70 Chestnut Ave, Extension, Leeds, MA Inquiry Made By: Jeffrey Morin 374.7799 Date of Inquiry: 7130114 Reason for Request: NEW CONSTRUCTION/HOOK INTO ANY CITY UTILITIES Municipal Sewer Main in Front of Location: Yes X No Municipal Storm Drain Available: 5'/2 deep Yes No Size of Sewer Main: Material: Age: Depth of Sewer Main: Length of Sewer Main: _ Size of Service Connection: Type of Service Connection: Tie-in to Sanitary Main Tie-in to Sanitary Stub Comments: V City Requires 6" cleanout Installed at City Property Line Note: If this ayailibility is for new construction,this form must be hand delivered to Bulldinci Inspector. A corresponding"sewer entrance fee"shall be paid priorto making any connection to the municipal sewer system.Arrangements of such installation shall be made with the Northampton Streets Department with a minimum of 5 working days notification. All work shall conform to Northampton Streets Department specifications. "L John Hall Sewer Department cc: Ned Huntley, Director DPW / Louis Hasbrouck, Building Commissioner �� MUNICIPAL SEWER/AVAILABILITY APPLICATION Northampton Streets Department 125 Locust Street Northampton, MA 01060 587-1570 A Department of Public Works Trench Permit and Sewer Entry Permit shall be required prior to any construction or connection activity associated with this application. Location: 70 Chestnut Ave, Extension , Leeds, MA Inquiry Made By: Jeffrey Morin 374-7799 Date of Inquiry: , 7/30114 Reason for Request: NEW CONSTRUCTION/HOOK INTO ANY CITY UTILITIES Municipal Sewer Main in Front of Location: Yes _ X No Municipal Storm Drain Available: 5 '/2 deep Yes No Size of Sewer Main: Material: Depth of Sewer Main: Length of Sewer Main: Size of Service Connection: Type of Service Connection: Tie-in to Sanitary Main Age: Tie-in to Sanitary Stub Comments: 2 V a T G - City Requires 6" cleanout installed at City Property Line Note: If this availibility is for new construction,this form must be hand delivered to Building Inspector. A corresponding"sewer entrance fee"shall be paid prior to making any connection to the municipal sewer system.Arrangements of such installation shall be made with the Northampton Streets Department with a minimum of 5 working days notification. All work shall conform to Northampton Streets Department specifications. _ John Hall " Sewer Department cc: Ned Huntley, Director DPW / Louis Hasbrouck, Building Commissioner �� ,Qi ti F7.qu}o CITY OF NORTHAMPTON,MASSACHUSETTS DEPARTMENT OF PUBLIC WORKS 125 Locust Street Northampton,MA 01060 413-587-1570 Fax 413-587-1576 oG a� 4( Trench Permit Number: Date Approved: 9�Z Revised Expiratiop Date: -/ (for City Use Only) EXCAVATION/TRENCH PERMIT EXTENSION REQUEST Pursuant to G.L.c. 82A and 520 CMR 14.00 et seq. (as amended) This permit extension request must be fully completed prior to consideration. Submit completed to Northampton Department of Public Works, 125 Locust Street,Northampton,MA 01060. This permit extension is issued under the provisions of M.G.L.c. 82A,520 CNIR 14.00 and applicable sections of the Revised Ordinances of the City of Northampton,including,but not limited to, Section 285-21. It is subject to all the same requirements and regulations that are required in the original permit and as amended as conditions of this permit extension. By signing this form,the applicant acknowledges that he/she has read and understands all the information set forth in and referenced within this application package and that they agree to comply in all respects with the requirements therein. Issued Trench Permit Number -- 2°d f T- _ ©�-�-' &,el dress . q(9 (2 ke- ( f Name of Apulicant Primary Phone# Street Address fir - ,�- - Emergency Phone# C City/Town 14'-/ State I A14 Zip d/ d r. o Email Explanation of reason for request for permit extension. 1 -A,--t ,I 1,,,,/ rrp- /of / c" C�`� ✓ L eti�t&-\ % Projected Completion Date: Dig Safe# -'7-0,`y5 1 a / y�1' Applicant Date: r`2,r - / For City Use--Do not write in this section Conditions of Approval: If applicable(See Attached) Permit Approval L/91✓�i/G1�611 �fr�/ - ��% ,tfara►c �� 201 Dir Pg.1/1,Excavation[Trench Permit Extension Request tIy'.14 �