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Building Permit Application(Signed) (1)APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 2.2 Authorized Agent: SECTION 3 - ESTIMATED CONSTRUCTION COSTS Building Permit Fee This Section For Official Use Only lhasbrouck northamptonma.gov 38 Avis Circle Northampton, MA 01062 Thomas Geryk 38 Avis Circle Northampton, MA 01062 (413) 320-9884 24,000 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side Rear L:______ R:______ L:______ R:______ Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) % # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ,Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO IF YES, describe size, type and location: SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition Replacement Windows 0r Doors Alteration(s) Roofing Accessory Bldg Demolitio New Signs ] Decks Siding Other 6a If New house and or addition to existing housing, complete the following SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Patrick D. Rondeau Install a 20 panel roof mounted solar array. System size 6.4kW DC. Thomas Geryk 12/30/2021 01/03/2022 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Name of License Holder 9. Registered Home Improvement Contractor: Company Name SECTION 10- WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 2 115680 4/9/2025 Patrick D. Rondeau