31B-312 (10) City of Northampton,
Building Department
212 Main Street
Room 100
Northampton, MA 01060 ,
phone 413-587-1240 F C1 C 1'V a
APPLICATION TO CONSTRUCT,ALTER, P411,RENOVATE OR DEMO ISH
utu 713
SECTION I-SITE INFORMATION
1.1 PropeMj Address: DEPT OF BUILDING INSPECTI s ,,lo<►..to be coil ,by
Q !
NORTHAMPTON MA 0106
for
N oy4+a,m p*t MA D Id(off zorH. ,
...
d10 4PA G Pad' -T(.Lj 1 o Y Eim.8R Co ol.ma
SECT-ION.2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
rnn6NA HQ L,59 CAN-DO S M41"h S" `Ilp'� No '1t.crlt l r�lbCOf�
Neuse(Print) Currant Melling Address:
(ae- C,Ontrod) Telephone
Signature
2.2 Authorized Agent: 2 l VIA
�J 102a N(N'rd W46tfidMA o►a�ss
Name(Print) Current Melling Address:
G
Signature Telephone
SErcn N 3.-EjTiMATED CONSTRUCTION Q=
Item Estimated Cost(Dollars)to be Official Use Only
completed b milt applicant 1. Building � (a)Building Permit Fee
21 , 82
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee �[
4. Mechanical(HVAC)
S.Fire Protection 7
6. Total= 1 +2+3+4+5)_ Check Number + 3
This Section For OlNclat Use Only
ate
Building Permit Number Issued:
Signature:
Building Commisslonerfinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)