25-055 (6) DeparMaenuuee,only�
City of Northampton ';; Status of Parm�t"� „” 5,p
Building Department Curb�CutlDrvev +yari
212 Main
Street �� � �
x eiw+grlSeptEc AvpilablEity F
\ j
Room W r/.wel1 AvaNWifty
0 1Y\ �� M t t7li �t'r't.YAt�4wl, lhl,A11 14Wr1A
Northampton, MA 01V,W1wFatphone 413-587-1240
iu,rr
d„.
72
alwt iv�lY;a�" Iltp�1M,1 ri v Y�„�.v
m, .�.vw,r ",_.u,.n, dV,r.w; ✓r�l A' „ 1.1, V ,,
. / ,s�r�� d1M�F
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVM'E O' DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
c� d b
G('D�S 1� ..,. ,m y office
1.1 Pr a Addr as; 11 --^^ -- Ma r- This soctlon to completed C
✓J�W' c�[7c7 P Lot,' 1 0 0J Unit
Zone Overlay District
Elm St District C13 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owngr,of Rec :
r -roor ; 1 Gfosr {�
Name(Pr t) Current Malling Address-
1 o-7
Sig t V
Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address=
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
Ecom feted by permit applicant
7. Building —9
dao (a)Building Permit Fee
2. Electrical - OCD (b)Estimated Total Cost of
J Construction from 6
3. Plumbing -'] Oz Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) p Check Number
This Section For Official Use Only
Building Permit Number; Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
�)Wpooc-q +Ao)r till-cl", �_Vvvl
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
1000/T000fi09 03 STddnS dos ov.IZ 99LLLZ9CTt XV1 Kv 0T:9 OZOZ/8T/50
Section 4. ZONING All InfOrmatlon Must Be Completed. Permit Can Be Denied Due To incomplete information
Existing Proposed Required by Zoning
This colunin to be filled in by
Building I)epartinciij
Lot SiZe
Fronta e
SetbsckqFront
y
Side L:� R: Ai
R:LjS:j
Rear
Building I leight
Bldg.Square Footage %
L
open space-fo—ot—age %
(Lot Arot minun bid g&paved -.7
parking)
of ParkingS ttccs ...... ...
Fill:
(volun20&1zeuti012)
A. Has a Sp9cIa[ Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:f--
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW
YES 0
IF YES: enter Book t Pagei and/or Document
................
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES NO 00'�
0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additi ons of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
.............
E. Will the construction activity disturb(cloaring,grading,ex ation. or filling)over I acre or is it part of a co'mrn' on plan
that will disturb over 1 acro-? YES 0 NO 07
IF YES,then a Northampton Storm Water Management Permit from the DPW is required,
f000/z000ln fog 03 SjddiiS J01013ij, 99LLLZ9CTf YHA XV TT:9 0902/9T/20
SACTI9SCRIPTION OF PROPOSED WORK Icheck all aaallcablel
New House Addition Replacement Windows Aiteratlon(s) Roofing
Or Doors d g
Accessory Bldg. ❑ Demolition t_1 New Signs [C]] Decks
(C] Siding Other[lm
Brief DescrilDtion pf Propo
Work: ' V
zo ,Aso
Alteration of existing bedroom Yes�'� No Adding new bedroom Yes o
Attached Narrative Renovating unfinished basement Yes / No
Plans Attached Rofl -Sheet
6a if view`house;.'and:o' 'addition tv''extsti
hO6 c'om fete tine ft)ilo
wih
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?AJO
d. Proposed Square footage of new construction. Dimensions 6x ~ 7 )L /
e- Number of stories?
f. Method of heating? c>a-u �ei �� Fireplaces or Woodstoves
�J /
g. Energy Conservation`C/oNumber of each
/mplia e. /V 7� _Masscheck Energy Compliance form attached?
h. Type of construction `V
i. Is construction within 100 ft.of wetlands? Yes 41—No. Is construction within 100 yr. floodplain Yes�No
j. Dopth 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 lUl/ Private well City water Supply
r1SECTION Ta -OWNER AUT14ORLZATION-TO BE COMPLETED WHEN
NERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, cA,ruill�e r
property as Owner of the subject
hereby authorize
to act on my beh If, in al att s relative to work authorized by this building permit application.
Signature of w r
Oat,
as OwnerlAuthorized
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,
��ll,�r
Print Name
Si natur®of b 11r/A onl
Data
fi000/CO00ln t'09 og .QddrkS do?jolaaj 99LLLZ9CTt% XVi 146 TT:8 OZOZ%8T%90
SECTION 8-CONSTRUCTION SERVICES
8SL_lLfcenspd Construction u ervlsor:
Not Applicable
Amo or t n 9.�loldor;
License Numher
Adtlre&s
Expiration pato
Slgrlat"o
Fel hone
�Rma7stewed'Horn
Not Applicable
Gompanv Name
Registratlon Number
Address
Expiration Date
Telephone
ffthe
N 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,.c.152,5 25C(6))
CompOnsation Insurance affidavit must be completed and submitted with this application. Failure to provido this affidavit will result
enial of the issuance of the building permit.
Affidavit Attached Yes....... O No..,..,
t'000/t'000ln t'09 00 STddnS ,zoloual 99LLLZ9CTf TFd KV ZT:9 OZOZ/ST/SO