23A-246 (5) Department use only
f Northampton
Status of Permit.
B.�if ng Department Curb Cut/Driveway Permit
Main Street Sewer/Septic Availability
SEP
oom 100 Water/Well Availability_
pton, MA 01060 Two Sets of Structural Plans
[Electric 7'
1240 Fax 413-587-1272 Plot/Site Plans
Other Specify_
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 Property Address: This section to be completed by office
I Q S N o n oi,L-A c k SAY-e e-4� Map Lot ---Unit
NIA 010G'9L- Zone Overlay District
Elm St.District------- CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
-__1
2.1 Owner of Record:
Carol J. Gray 815 South East Street. Amherst, MA 01 002
Name(Print) Current Mailing Address: 413-297-1075
Telephone
Signature
2.2 Authorized Agent:
L uvt-s
Name(Print) Current Mailing Address:
��i
07�6
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use 0
_ completed �ermit applicant /A
1. Building (a)Building Permit Fee
9,87)C
2. Electrical ]
(b)Estimated Total Cost of
Construction fiorn-(6)
3. Plumb;ng Building Permit Fee
�TMechanical(HVAC) 1
5. Fire Protection L)
6. Total= 0 +2+3+4+5) 9.8701 Check Number
his Section For Official Use OEly T-
,-A-A4.e-
Building Permit Number: Date
Issued:
Signature.
Building Commissioner/Inspector of Buildings Date