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23 Ford Crossing - Building Permit Application
Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit I ' A 212 Main Street Sewer/Septic Availability Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 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: Map Lot Unit Zone Overlay District Cir it- SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT Elm St. District CB District 2.1 Owner of Record: 's -i- Name (Print) Current Mailing Address: Y 4 p M h f` �— Telephone b 0 2.2 Authorized Agent: i` vb-SD Name (Print) M A -P -K (.co W v,4, Signature SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Building Permit Number: Signature W- `f r �T o Current Mailing Address: I 3 ,— — g'a�"'? Telephone Official Use Only (a) Building Permit Fee (b) Estimated Total Cost of Construction from 6 Building Permit Fee Y ''1 1,7 , ' I Check Number This Section For Official Use Only Date Issued: Building Commissionerlinspector of Buildings EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING j_ — (5 �e L-17 } 2 0 N s[ r"- r t ,r,y All Inf rmation Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled' y Building Depanment Lot Size Frontage Setbacks Front Side Rear L: R: L: Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) % # of Parkin SDZS Pi . olume & Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW © YES Zg (g M A --4^p Ie - IF YES, date issued: 1r7)16 PLXtj IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book o Page 19? and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 1P DONT KNOW O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: e YES O D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb clearing, grading—ravation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. p i t)e A -SC go� k-d- SECTION 5- DESCRIPTION OF PROPOSED WORK check all applicable) New House Addition ❑ Replacement Windows Or Doors L] Accessory Bldg. ❑ Demolition ❑ New Signs [fes] Alteration(s) ❑ Roofing ❑ Decks [Q Siding [0i Other[L71 Brief Description of Proposed �� r Work: a tr �+ Yu Alteration of existing bedroom Yes \- No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes .,�< No Plans Attached Roll - Sheet 6a, If New house and or addition to existing housin-g. complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit. Number of Bathrooms c. Is there a garage attached? ,I S15c_ d. Proposed Square footage of new construction. A-ri" P'C4A'1EJ> Dimensions Q\M�t ��f e. Number of stories? f. Method of heating? M I -KV P 1 S M l I- S f t71 Fireplaces or Woodstoves Number of each — g. Energy Conservation Compliance. - ! Masscheck Energy Compliance form attached? x h. Type of construction 15,9 i. Is construction within 100 ft. of wetlands? Yes >< No. Is construction within 100 yr, floodplain Yes >C_No j. Depth of basement or cellar floor below finished grade i- 0 N L k. Will building conform to the Building and Zoning regulations? �< Yes No. I. Septic Tank City Sewer X Private well City water Supply X_ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT (jp as Owner of the subject property hereby authorize Uv 6__rK to act on my behalf, in ali matters relative to work authorized by this building permit applicat Mf -PK L w '�/[�t�a-a Siqnature of Owner Date I, ! ent ereby and belief. the statements and information on the foregoing application are true a Signed under the pains and penalties of perjury. Print Name of OwnerlAQent Date as OwnerlAuthoriz accurate, to the -best o my knowledge SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Applicable ❑IName /,�1,��Not of License Holder:V`� F�1' �'�/ t ��CV`a t/G D 1/v ,Z� (MA44* d � q I Y �O License Number -�—Z 9 ��I Expiration Date `fff (V4 LEtAniLP"1j Address MA -4: Signature Telephone 9. Registered Home_ Improvement Contractor: Not Applicable ❑ T /oj 53b Company Name Registration Number 4H �7 i o 1�I1�-,q,l�n Y� �1 6 h Address Expiration pate yQ —Telephone�'� �a SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 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. I Signed Affidavit Attached Yes....... X No...... ❑ 1