31A-024 (2) , p
p , . ',E Grim of Northampton 1 _ * _ _:
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DEPARTMENT OP DUILDfNG INSPECTIONS '
212 Main Street ' Municipal Building
Northampton, Mass. 01060 - r'
«'ORK R'S COMPENSATION INSURANCE AFT DAVIT
CAL ` v t / , LI1,1
-
-- -- -__ - -- _ - - -- -- -- (li ccusxJperrni cite )
. with a principal place of business/residence at.
�/ �kn .
Or 6 --
of v Ge --- '� --.r' N ) ` i �`a -"�" -o ne : ' 1)— j`�`.,/ ' / ' L
f G U ) y /
(str icil /s1atc/zip)
do hereby certify, under the pains and penalties of perjury, lilac
(41 un an employer providing the following worker's cotnocns::non covetage for Inv
employees wording on this job.
o I .i in fC GJ e 7 214 7 I! b'7--b .?- — 1 - 11
(nstu -12 Corsr. y) (Policy Narabcr) C=- ;pinion Date)
( ) I am a sole proprietor, general contractor or homeowner (ccie one) and have hired
the contractors Listed below vy'ho have the following •worker's comn:.nsadon po!!cies:
(Name of Contractor) (In oranc-o CornoanyiPoiict Num :) (1=_xpl.muon Datc)
(Name of Contactor) (LI15uran CoMDa.nv /P0t1CY Nll.CilC' =r) (Evou Date)
(Name of Contactor) (I.nsurancc Company/Pol;cy I`ittmb:-r) (Expir000 Date)
(Name of Contractor) (Lnsurano Company/Policy Numbs) (Ex�irtion D'art-)
(r_aac3 acldi:;ocl rbrd tf ncocz...ry to mc'u-de calorn.rr pct rg ro all peas- ._.GO:
( ) I asn a sole proprietor and have no one woring for nle.
( ) I am a home owner performing all the work myself.
NOTE: pleat be ew-xre t},,. wtrnic hear_owven wbo asp lay pious to 63 r , cO - -__ -- .: oc) c rc , ork on . ds E of
ont rz)occ tti-^, Lm. tnvd in IA-bid, Lb i>ornena. aver rc,Lido or oo the gouarii zppttttn-r_ thco-o �.c nit . )c:l1y ward - -cd to be
eployct ux'.c the t.cekio tioa Act (GL152 o 1(5) ).. application try a bomcoaraa fa c l: v a po'nut rn_ y c.r1,-rW the
IcgaJ rtom of ca oxploy-c under dip Worke!. C m_pocrutioa An
-1 I tout:rr,.- ad t$n > Dopy of till, rntcmcm cia.lLy bo fo. -v- riled to tba Dcpu„Y
to* of Ind A Mo
rid d 1 OILioo of lavc.00 for to
c ovtotsc vniEclioo and th_.t f_iitae to eaztrc eovcrnse to cicr soctioa 25A of }.MOL 152 an Iced tc the .. irtirm of utmm-tr pct, 1iics
oomiomg of a fiat of trp to 2 1 So0.00 and/or roprisoumcji of up to on yr to,i dvd pcO.01.10 in tc form of a Stop Work Order and a
fire of 5100.00 r thy rga. nA me
F or d n -%
cp.rtr-1 u,c only
P ermit Num bcr _____
, i l 's-------------- ---.,
M.ap: : - Lot" _ --
Signature of Licci?scrlPcnnittcc Date - -
een O ONS TRUCTOWSERViCES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ��� 1 d f OD S 0 7)
License Number
.. X "'- r - 1
Address Expiration Date Arta oi 0 6
Signature Telephone
1 / 4 -/ /t `/
-'� ,_. - _.:r o a xe - : ,;r fl... ;tar
��� a�A e� .- . Not Applicable ❑
Company Name Registration Number
3 - ( 2
Address Expiration Date
Telephone - �� —
S CT1O » a., *RIKERS' cOMPRNSAi'LON 11441MAN A FtDt 1T (M GtL;t 152, 14'00
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 ❑
The current exemption for ",homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
-- p
— Tpkt*LD GRIP7tO ; Q ROP l O . #0 I appj £a`fatej
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: /Ze - 1 E-x ' J f-`C /f 1-^*' -
Alteration of existing bedroom Yes ✓o Adding new bedroom Yes i/
Attached Narrative o Renovating unfinished basement Yes ✓ No
Plans Attached Roll o • Sheet [V
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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth 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 Private well City water Supply
" O Iii i. ii 1t 14 tiiONl - � *Ni � MP 1 i !i
o
I w s si no 1"!"i ic't i iOrkt k BUtt;i �A PEtMIT
I, h't 0._ - i t a-c'd. - `-i `f , as Owner of the subject property
hereby authorize ® f �f � to act on
my b- 1 -If, in all matters relative to work authorized by this building permit ap licaton.
g9 A
Signa ure of Owner Date
I, 4 14 , as Owner /Authorized 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 penies of perjury.
(7) i v e—,,. J le / ,-,
Print Name
L ` I
Signature of Owner /Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
I ✓: , ` < r. This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
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 'V 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:
42 FRANKLIN ST BP- 2011 -0811
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 024 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0811
Project # JS- 2011- 001333
Est. Cost: $5850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 17903.16 Owner: SIMPSON MARIAN V H
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 42 FRANKLIN ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:4/8/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/8/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner