64 Meadow St Northampton Building Permit AppThe Commonwealth of Massachusetts
Board of Building Regulations and Standards
W& Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
(a H m eOL &oj ��SA r 'e e A-
1.2 Assessors Map & Parcel Numbers
Map Number Parcel Number
L la Is this an accepted street? yes no
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.6 Water Supply: (M.G.L c. 40, § 54)
Public ❑ Private ❑
1.7 Flood Zone Information:
Zone: Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: A
C.d h GY 0, r i C lL2 r
Name (Print) City, State, ZIP
("'k ►( -) S+ '-113 -303-Dyly
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO (check all that apply)
New Construction ❑
Existing Building ❑
Owner -Occupied ❑
Repairs(s) ❑
1 Alteration(s) ❑
Addition ❑
Demolition ❑
Accessory Bldg. ❑
Number of Units
I Other Specify: 50-Q0.-( f r
Brief Description of Proposed Work': (v\t ,4 ' on
CJ QJ,`ne.ls ov'\ \roo J� Ce Si 6. n(k- . _ (�. 8 k-W sot0..V-
r� .
13
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
(Labor and Materials)
Official Use Only
1. Building
$ L.I S 8 6
1. Building Permit Fee: $ Indicate how fee is determined:
ElStandard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
2. Other Fees: $
List:
2. Electrical
$ '--' 1 5 Z
3. Plumbing
$
4. Mechanical (HVAC)
$
5. Mechanical (Fire
Suppression)
$
Total All Fees: $
Check No. Check Amount: Cash Amount:
0 Paid in Full 13 Outstanding Balance Due:
6. Total Project Cost:
G
$ 5 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
ca,r k n
C5' _ 7Q75o l a0o?3
License Number Expiration Date
List CSL Type (see below)
Name of CSL Holder
X
3 V\ c� C o n Q n Q
Type
Description
No. and Street
u r U SU
y �C) n �+ L
U
Unrestricted (Buildings u to 35,000 cu. ft.
R
Restricted 1&2 Family Dwelling
City/Town, State, ZIP
M
Masonry
RC
Roofin Covering
WS
Window and Siding
SF
Solid Fuel Burning Appliances
-7 7 ,1-1 b 96 /p a r S o Q @ p C, vc-a c.h o 0,
I
Insulation
Telephone Email address
D
Demolition
5.2 Registered Home Improvement Contractor (HIC)
2 O y l t - i d0a
HIC Registration Number Exp ation Date
HIC Company Name or HIC Registrant Name
—1 e � *MC ��C- C /cam..,�Ja�
No. and Street
D/.-6--.?7 813 - 638-S17$
Email address
City/Town, State, IPA Telephone
SECTION 6: 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.
Signed Affidavit Attached? Yes .......... V No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name (Electronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contas application i e d accurate to the best of my knowledge and understanding.
a/i��aa
P 'nt er's or Authorized Agent's Name (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" maybe substituted for "Total Project Cost"