31A-228 •
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Crrt of Northampton I = ` _
4 is f �lasanrhncrt(e — ,
,c, = DEPARTMENT OP BuILDfNC INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE AITTI)AVIT
T '4y P jS4 /►v,
(1i ccuscc/permi nee)
. with a principal place of business/residence at:
ff (1t .itd- t `14. --- ( phone:.') sZ 9 'I LZ
(sTr =i/ci ty /sta(c'z p )
do hereby certify, under the pains and penalties of perjury, that
( am an employer providing the following worker's coinocnsrnon coverage for my
employees worong on tins job:
COCA
fc? / :CIA i', OC74 —) -►t
(Insw - ,o Corm =ny) (Polio: Nurnbc_r) (r : Date)
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the contractors listed below who have the following worker's comoens2don policies:
(Name of Cont:aeto: (Instlranc: Cotnoanyi oue, Ntun r) (Explrauon Date)
(Name of Conaaczor) (insurance Company/Policy Nu.mc-.!r) ( ). Date)
(Name of Contractor) - (Insurance- Company/Policy Ntlmbr:r)- (Expiruoa Date)
(Name of Contractor) (Insurano Company/Policy Numbs) (Expiration Datr)
( addit:o c'xct if n<- .—rary to ioc). u4 infocvn.r.ioo prtainin6 to aL ocar-,--......o:a)
( ) I am a sole proprietor and have no one working for me.
( ) I am a hone owner performing all the work myself
NOTE: plcs: be cwarc till. w'trJc bcar_ouv;ra wbo cap1oy peace to da c .i.... a-M as -- ac c rrnir' ori, oar d•` th of
not arac than W tmfz in v.- ich the bornoot.vcr rcydz or ca the Qot:rrd3 aapurtcn=1 them c.-r nx G-, -.11y oen:docd to be
c-Iplhyc7 "M-',, the wt:rk&Z. _ti on Act (G L 15Zn 1(5)), _ppl c tiro by n bomno far :. I: co -- oc t.�, ruin r>=y <.;d tbc
1rsya1 rtnnar of co oxployor under ctan Wor4.xer CompocTxlioo ,l.ot_
1 I undri
crrnd that x copy of (hi, m.c000am may bo for- d.
- ,uod to tbo pcgam
rtooa of ),,,4-. .I Acect - e OfLoo of Ira +o
a uoo for the
oovengc vcriGetioo and that f_ilta to ccauc covcr trodcr soaion 25A of Mal_ 152 can taxi to tt>: iniosi:tioa of criminal prna.13n
oomisig of a frnc of up to S1,300.00 and /or umlaisorancn of up to ooc yt r ersd civil pm,lia in tSC form of. Stop Wort Order end e
fire of S 100.00 a day tnc
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or
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// Pe-rant Number
Maw: l,ol
I SEC710N; 8 CONSTRUCtION
_....
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : /A-Oro 16 S 3 50 ?.?
License Number
? Jf v, 'L 4-e-4" -- - ' 1�
Address Expiration Date
. (1 sxv Signature Telephone
V s ` i v 1 4;. s r. r
� = ��,���,.,�'�� ����w���� A �' � � �s '
� ��s :;" � ����:� �:� 4 Not Applicable ❑
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Company Name Number
Jry e ay
Address Expiration Date
Telephone
SEc1 ON 1b WORKERS' COMPENSATIO, '° 'WOO a 001140.G L 152, § 2 50(60,
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
ECTIaN S., DESCRIPTION F PR . R ( (c1ecl4 all applicable)
v, a
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [VI
Siding [ ] Other [ ]
Brief Description of Proposed Work: . 2u i I d ek c Lc k L'' et i - er I
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes ✓ No
Attached Narrative ❑ Renovating unfinished basement Yes v
Plans Attached Roll ❑ - Sheet t;.
i 4 ?:: :' '= 6 .f1 0'' 0 L : "- 2.1, ..:-. `2.1. f 1: '. T '� ; ' '''' :
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
ECT`I ya p R '!' ;6407:, 6 1 k ctom )i4D, li ,E
N T
OWNERS' AG OR cti TRACTOR PPUE to i :iG P MIT
I, —ro l Yv` ,, !' , as Owner of the subject property
hereby a� . on. O�0 f �!` J �. to act on
my beha , - all matters relative to work authorized by this building permit application.
- 611.1.‘
Suture • • ner Date
I, TT "'"''''�' f' A '`� , 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 und th paains and penalties of perjury.
Print Name /]
4 6 /
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
This column to be filled in by
Building Department
Lot Size gel .4i,
Frontage
Setbacks Front .Q ` /a C FkP` C
Side L: R: L: Nil 141 * -'G �-
Rear 1 f ' 3
Building Height fib
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 V 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 ere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
.. ... . , . -,
.,1C ).
, 1114 t
_....
.✓ ,
File # BP- 2011 -1015 filtAA
•
APPLICANT /CONTACT PERSON OLIVER ISELIN
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 28 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 02 1
Fee Paid �'C� �V
Typeof Construction: CONSTRUCT NEW DECK& STEPS
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
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved 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
:.
ignature of mg • icial 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.
rkt KON °
28 HARRISON AVE BP- 2011 -1015
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 228 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit # BP- 2011 -1015
Project # JS -2010- 001695
Est. Cost: $8100.00
Fee: $50.00 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: 28 HARRISON AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:6/15/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT NEW DECK& STEPS
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 6/15/2011 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner