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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