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= DEPARTMENT OP BUILDING INSPECTIONS ' - -,
212 Main Street Municipal Building
,>
Northampton, Mass. 01060 r p'
WORICEI2'S COMPENSATION U SU ..N`CE AIF`I( J)A\rrl
0 L/ t/_ ( 1,,,SSL /"...1 S
(li ccnscrJpermi ttcc )
. with a principal place of business/residence at: °)v
(strct/ci t /stat.c/zip)
do hereby certify, under the pains and penalties of perjury, that
(�am an employer providing the follaavinL Worker's coinpensat)on cove age for illy
employees \volbng'on this job
C . .9. C2. c78Yyici } - I-ia.
(Ins s- c Company) (Polio: Number) , (Expiration Dam)
( ) I. aoi a sole proprietor, general contzactor or homeowner (c de one) and have hired
the congactoi-s listed.below who have- the following worker's cot en_auon policies:
(Name of Contractor) (lnslranc Cornpany /Pout; Num!Yr) '(-x_rtrution Date)
(Name of Contractor) (1nsurancc'Comoany/Policy Nualbcr) (L >piraion Date)
(Name of Contractor) . (Innrranc; Company/Police Nambar)- (Explr tioo Date)
(Name of Contractor) (Insuran ce Compaay/Policy Numbs) (Expiration Date)
(ccianb addi'Sdc.r £beet if no c ir - to ¢kook inf«zl,aoo pertaining to .0 -- orn )
( ) I axn a sole proprietor and have no one world.ng for me.
_( ) I ant.a home owner performing all the work myself.
NOTE: Ql sc be aoruc thn wi.^jc bomcowvc» t+bo ¢»ploy petons to do r• . +•- a a - vn-too n- repair work on . dwelling of
not MOM tfun tY.i =tits in uaid) the botznow-oer re idc3 ocoo the grounds zpp co r the-do r_-c otx crncretYy oeesid +d to tx
empioyn, uodcr the wecitela o=tvcnizlion Act (GLt 52;331'(5)). ecolir>boaby . boeueo'ica foe t tick'- or persnrt oeoy cs- deoee,tbc
I cge-J to rut-b. of ao ceoployor uodcr dso. Worko Coaapoo .i pn A.
1 uodortAnd duct a copy of thi. rrafvaaa o may bo foron rimco
<rded to the Dopaa of lo.4." -ll<I Acodcoo' Mon of Ls for the
c oocntgc Ne oo acid th :t L-,ilto-c to socute covers zc to der soctioo 23A of 1+.44L 152 can Icad tt the imposition of cziatioal pcntIbcs
comiAmg of a floc of up to S1.500.00 and/or o a risoccx of up to one yczr er d ri til pcni►tio form in tt fo of& Stop' Wow Or and •
fun of S100,00 a' day LEaiasf etc
For dco.rtnrral u,e only
[ ��O , e Permit ll Wit
v r A'L7pg Lot
—
---,,, Signa ture of Lioarscc/Pct»ti U to .
1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
OL 1 VET JrEt/ 0.7 5 0 3 - .7
License Number
3 ‘ ,fe r ✓ :cue 'l ,-.r- LI qj - 1 s' 1 I
Address Expiration Date
9 r /.c.4, % ylilfil t�) 10 1� 0
Signature Telephone
(..
,i" "TV - ft,z
Not Applicable ❑
JYL� / 0 7 S--
Compan Name Registration Number
Address Expiration Date
Telephone
c .a.
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 12 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. CMR780, 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 Suet' 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 injuriesnot 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 "hoirieowner" 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
f a �
New House ❑ Addition ❑ Re lacemen . indows Alteration(s)
p oofing ❑
Or Doors r
Accessory Bldg. ❑ DemolitionDe New Signs [ ] , Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Wo �Zaw.o / . tc l`-",- / fi t ye (ate toy- =d r j.4j , 1-• /f R0 .) ,.i 1', ct.o
Alteration of existing bedroom Yes "� No Adding new bedroom`_ Yes `� No
Attached Narrative ❑ Renovating unfinished basement Yes ✓ No
Plans Attached Roll 0 - Sheet Q
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
I, I� cIr 144. --1-
µ'`� t , , as Owner of the subject property
hereby authorize // L' e ale!' •to act on
my be in = l =tters relative to work authorized by this building permit application.
[ .� V -- ---L t d , �l
Signature . 17 er . Date •
IIIIIIIIIIIIIIIIIIIIIIIIJIIIIIIIMIIIIIIIIIIIIIIIIIIIIF
i i
I, '"7"x'" e l ` ", as = ' uthorized ' _ e
hereby declare that the statements and information on the foregoing application are true and accurate, to 1 - o my
knowledge and belief.
Signed under t e pains and Penalties of perjury.
../...s
Print Name
Signature of Ow er /Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
^^ + This fi b
/' 0 UGC, fi Buildin column to be g Departm lled in by
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 ' 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:
, O`er
_City of Northampton
�p10 Bui ding Department
N 1 '\ 21 Main Street
°'Room 100
Northampton, MA 0106 0
phon 413-587-1240 Fax 413 '587 1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1,1 Property Address:
ZG /iani1l.- /-—
f t
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<�34' fi Si' `'C^3 .a,,.zx . ,waK <. ' .�.«, ,�. > {. z< s".,as "$;. '�t,��a"'PS3",�
2.1 Owner of Record: 1 y I ;�
7--c-,, QC a r , 4. C e 7 (Jttr�Qdotr�.+ Za ►`fa —� (
N. 1,:,.L. t / " Current Mailing Address:
•
i It. ► Telephone
oignat
2.2 Aut orized Agent:
Name (Print) Current Mailing Address:
/� y 1 2 y
Signature Telephone
Item Estimated Cost ( to be t1
comsleted b sermit a. slicant s � r� s � �
, gym S Fr ''
1. Building . , ,° ' , A � ' '. A�� Ft � �
d..._.. a F R. Y c .X1x .@ b 4
2. Electrical�� �-
3. Plumbing ,� w.5v
y py ,
m `nsrY '; , Y �" 4
4. Mechanical (HVAC)� � ��
5. Fire Protection / / 1-70 . - ' �.�
6. Tota ( 1 + 2 +3 +'4t5) � � `€
.# } T `S R F `t4 } §. ?' : k R ,, i $ F° � { d
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w xi ... `,. ' t ro s t o 4 a
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,. ..... mawwftw>._.rort ., ...,x��o�.�w'�as3�aL�uwr4w �, ...- ,.,
File # BP- 2010 -1160
APPLICANT /CONTACT PERSON OLIVER ISELIN
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 26 HARRISON AVE
MAP 31A PARCEL 228 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / Q />1
Fee Paid 4 / 7
Tvpeof Construction: REMODEL KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 039073
3 sets of Plans / Plot Plan MUST ADD I R. &O S i'M E / CA) 6 T6CW -
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
p proved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
/ 6 z3 16
Signature of Building Official
Date /
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
BP- 2010 -1160
GIS #: COMMONWEALTH OF MASSACHUSETTS
F . .. , , .. CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1160
Project # JS- 2010- 001695
Est. Cost: $32950.00
Fee: $197.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 8973.36 Owner: MARGHERITA TONY & DEB BERNERDINI
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 26 HARRISON AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:6/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN - MUST ADD WIRED
SMOKE /CO DET
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 6/23/2010 0:00:00 $197.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo