PermitPG1SECTION 1 - SITE INFORMATION
Department use only
City of Northampton
Status of Permit:
Building Department
Curb Cut/Driveway Permit
r 212 Main Street
Sewed8eptic Availability
`a Room 100
WaterNVell Availability
Northampton, MA 01060
Two Sets of Structural Plants
phone 413-567-1240 Fax 413-587-1272
Plot/Site plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
K>u-'q Ave,
Map Lot Unit
�' �( I f
Zone Overlay District
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Elm St. District CS District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: j
L
tc< 5-0 o
Name (Print)
Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
colw &04k
Name (Print)
Current Mailing Address: Uj i f fir- MA Mfr 2.
01-21Z-2ZZ�-
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by permit applicant
1. Building
(a) Building Permit Fee
2. Electrical
/p ,
(b) Estimated Total Cost of
Cid
Construction from 6
-3. Plumbing
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
! l
6. Total = (1 + 2 + 3 + 4 + 5)
66 076 M
Check Number
This Section For Official Use Only
Building Permit Number;
DateIssued:
Signature:
Building Commissionerllnspector of Buildings
Date
F