32C-044 (16) -'" GCPPONWEAL'SH OF MASSACHUSETTS
;I �9' - CITYOPT
F NORTHAMON
APFLICATION FOR CERTIFICATE OF I ;SPEC; o::
Date -PA 7 r I Fre acquire,: ( Amountil�V'%• �
NOV � 0 s ( ,�) No Fee Requ_red -
In accordance vit}c t'1) jiprn rlaiOns of the Massachusetts State P.ullding
Code , Section 1O8,15„ r hlY;eb} Sp*1j- ib} a Certificate of inspection for
the below-named premiseslocated atthe following adcress :
Street and Number 7 a ['//z_&ns»..;r i)/()7-
Name of Premises %/.4. 'r - A7�-�•- Je�m. �F yn�Try TEL# y"",f�..e's..�a-o
Purpose for Which Premises 11, Used O._.}-k,,24-7. !V.
License( s ) or Permit ( s ) Required for the Premises by Other Governr.ental
Agencies : PLEASE FILL IN BELOW
License or-Permit - _ Agency
c..s/7 "T ,/ /_..,bL //4=..c.ed
Certificate to be Issued to hl,.. „f;,...c� /.,,.,N —Nq •%T
Address 7C /0c CA in,- S'.r
Owner of Record of Building ;Cic:yn,in T 5f/ 5ccy
Address in e2- 5r ,c,.;>,,,, 4-,n�,�
Name of Present Bolder of Certificate /{A.,,ss,y„f, q,n;, ,7,-=ar.:._4...J.-
Name of Agent, if any 2nn S, .. TEL# Sid d's_ru
SIGNATURE OF PERSON TO WHOM TITLE
CERTIFICATE IS ISSUED OR HIS/i-c'7C ��JJ
AUTHORIZED AGENT .
DATE
INSTRUCTIONS :
1 ) Make check payable to: CITY Of NORTHAMPTON
BUILDING
2 ) prehtein tfihif lCa_nnlication with your check to: INSPECTORS' OPFICE
PAL212 MAIN ST. NORTHAMPTON, MASS. 01060
PLEASE ROTEi
1) Application form with accompanying fee must be .submitted for each build-
ing or structure or part thereof to be certified .
2) Application and fee muet be received before the certificate will be issued .
3 ) The building official shall be notified within ten (10) days of any change
in the above information. -
CERTIFICATE / EXPIRATION DATE:
FORM SECC-3-74