01-Building-Permit Application
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
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:
____________________________________________
1.1a Is this an accepted street? yes_____ no_____
1.2 Assessors Map & Parcel Numbers
_____________________ ____________________
Map Number Parcel Number
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 OWNERSHIP1
2.1 Owner1 of Record:
________________________________________ _________________________________________________
Name (Print) City, State, ZIP
_____________________________________________ _________________ ___________________________________
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________
Brief Description of Proposed Work2:_________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost3 (Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:_________________________________________________
____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:__________
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Fire
Suppression) $
6. Total Project Cost: $
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
________________________________________________________
Name of CSL Holder
_________________________________________________________
No. and Street
_________________________________________________________
City/Town, State, ZIP
_________________________________________________________
__________________ ______________________________________
Telephone Email address
_____________________ ______________
License Number Expiration Date
List CSL Type (see below) _______________
Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
______________________________________________________________
HIC Company Name or HIC Registrant Name
______________________________________________________________
No. and Street
________________________________________ ____________________
City/Town, State, ZIP Telephone
_____________________ ______________
HIC Registration Number Expiration Date
_______________________________________
Email address
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 ………. 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__Wright Builders, Inc_ to act on my behalf, in all matters
relative to work authorized by this building permit application.
______________________________________________________ _______8/16/2022_______________
Print Owner’s Name (Electronic Signature) Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_____________________________________________________________ ______________________
Print Owner’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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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” may be substituted for “Total Project Cost”
CITY OF NORTHAMPTON
SETBACK PLAN
MAP:_______ LOT:________
LOT SIZE:____________
REAR LOT DIMENSION:_____________________________
FRONTAGE_____________________
REAR YARD _____________
SIDE YARD______________ SIDE YARD______________
FRONT SETBACK_______________
1"=150'
42 RUSTLEWOOD RIDGE
The information depicted on this map is for planning purposes only.
It is not adequate for legal boundary definition, regulatory
interpretation, or parcel-level analyses.
4/12/2022 2:49:22
Property Information
Parcel ID 11 -022-001
Address 42 RUSTLEWOOD
Total Value undefined