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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street Municipal BuildinE `c
Northampton, Mass- 01060
` \'OREIZ'S COMPENSATION 11 AFFIDAVIT
LISe
(It ccnsccJpermi ttce)
th a principal place of business/residenc at:
(vo)
(sue t/city /stale(z3p)
do hereby certify, under the pains and penalties of perjury, _hat
(.11: aro an employer providing the following worker's coinpensCuon coverage for my
employees wormng on U11S job.
GJ C` L,^ f r-4, 0 7 / 01 1 ( c?
(lnsur-no Company) (Policy Nu (T_.-piruon Date)
( ) I am a sole proprietor, general contractor o homeowner (ccie one) z_2d have hired
the contractors listed below who h2ve the follow g worker's cooDent2don policies:
(Name of Co^mec or) (Inst ranc Comoa yPcuc; Numbs;) - spt;dt :on I}atc)
(Name of Contractor) (lnstuancc Comauv /Polio• NunJccr) You Lion Date)
(Name of Connector) (Insurance Company/Polic) N,unbe_r) (Expiraon Date)
(Name of Contractor) (Lasnrano Company/Policy Numbs) (Expiration Datr)
(aaa Gl zddm a'xc: tf ncemn.n. to ine'uct- informL'i on p cazanant to an occr_r— :s)
( ) I am a sole proprietor and have no one worming for me.
( ) I am .a home owner performing all the work myself.
NOTE: plc s be aw c t wt: JC boors wt>o employ pcsons tow caibor t, coo c tc x work oo a d' rW i of
nos roccc tt:_n t`om =to in w'aicti the bo ,o".vvcr rmidm or oa the pot,ods apputYctt:J' tb o LT rnx g>oOJY oces :d_ to tic
c tployt s u v -
tho s o- lino Aa (0 LI52,s t (5)), appticsboo by a bomwwva for < 1, v a permn r_ y c.idcnm trc
I<gil rtsaac of an .ozployoc under ciao Woriroe, Coeagocsxtioo Act
I kindc:,zvnot that > Dopy of thi. crziocooco us.y bo fa-wsvdod to tbo Dcpartascot of InAau,d Aozoo -ii' Otrrioo of lraiuz000 for th.
covo -sc vtsifit= ion and th_t E Jtn-o to sccurt covcrnsc ttndcr sccuoo 25 A of MCI_ 152 cm Io"d to the posilioo of mmiaol pcoallics
000n.i. of a floc of tip to S 1.300.00 and/or conprbocccacIi of up to Doc yen cad civil 1)(3111 Cl >a cs (aim of a Stop Wort Order and a
tiro of S 100.00 a city against tnc
F or dgsti'trt»l u.c only
Pcrtn't Hun)b>cr
Sit natum of Liccn cc/Pcrtnittcc 3 e
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 0 L I V t YL C L/ e 2 7 C
License Number
2 b f e rv. - w ( ,.a., 9.,- CA. 4 '0- - 1
Addres� Expiration Date
i1 - J / - ' L2y
Signature �' Telephone
9. Registered. Home Improvement: Contractor Not Applicable ❑
Company Name Registration Number
:" - y - /O
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, g 25C(6))
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 ❑
11. - Home Owner Exemption
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
SECTION; 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition ❑ Replacementdows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. [2( Demolition ❑ New Signs [D] Decks [I( Siding [D] Other [D]
Brief Descriptio�ryryof Pro•osed /Z C.. a- el l fX + ' J I-.f (.�'..' dyy I , �G.� - �r'c - %� a ;✓�� v �� � t v c.:
Work: N8 4c1n. G‘.10,. P .. _,. / . ' ..._�� ,,.� • ?Pe .
Alteration of existing bedroom " Yes No Adding new bedroom Yes 17 No /C/ %a I
Attached Narr- ' , - Renovating unfinished basement Yes ✓ No
Plans Attach • Ro - Sheet
sa. If New house and or addition to existing housing, complete the following:
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. Masscheck Energy Compliance form attached?
h. 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
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
÷t L ' �' re / , a wn uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the es of my knowledge
and belief.
Signed under t e pans and penjtias of erjury.
Print Name
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size l ra -+ ci 3'Q
Frontage
Setbacks Front /5--
Side L: R: L: �{' R: 11'`1 L,1
,
Rear / Z
Building Height 3 a 70 20/
Bldg. Square Footage Lug a % 11 i I,
Open Space Footage
(Lot area minus bldg & paved .3 s'b ? 2.811 J 1 O
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ` DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO a
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Iepartrrtent`use only
City of Northampton Status of Permit:
Building D CurbCut/Driveway Pe€m
212 Main Street Sewer /Septic Ave-1100i Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 -587 -1272 Ptot ste J a
Qther�'Splepify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1 ,4
r LiaJ
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
r - KQ,,,��,,```.� „� / ✓G Map __Lot Unit
J ,J Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: + /�
- ` �' °�" cz f Q }' /� l� 36 J t' t vi Ct �5 >�J' /Lt.
Name (Print) / Current Mailing Address: . L y
®°
‘ei (6' .n!'r Telephone
Signature
2.2 Authorized Agent:
/111. .1 Se /� „l b .
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ` �� (a) Building Permit Fee
b
2. Electrical (b) I ( b ) Estimated Total Cost of
7 Construction from (6)
3. Plumbing Building Permit Fee
/L
4. Mechanical (1-IVAC) u
5. Fire Protection it I 'fir
6. Tot (1 + 3 + + 5) f Z � - V 8OO . Check Number 7� 4 0 2
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0398
APPLICANT /CONTACT PERSON OLIVER ISELIN
ADDRESS /PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 57 KENSINGTON AVE 3' /
MAP 31A PARCEL 241 001 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 /33 9 n'� „,,,�
Fee Paid r `�
Typeof Construction: CONSTRUCT 12 X 22 DET GARAGE, REMODEL KITCH,MSTR BEDRM &
BATHROOM, INSTALL REPLACEMENT WINDOWS
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
Demo ' ion Delay
1 0 .. Acs
Signature of Building Officia 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.
51 "SN a BP- 2010 -0398
GIS #: COMMONWEALTH OF MASSACHUSETTS
4 I ap:B1ock: 31A 241 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 -0398
Project # JS- 2010- 000539
Est. Cost: $127400.00
Fee: $764.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 4922.28 Owner: MALTMATES LLC
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 57 KENSINGTON AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMAO1060 ISSUED ON:10/16/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 12 X 22 DET GARAGE, REMODEL
KITCH,MSTR BEDRM & BATHROOM, INSTALL REPLACEMENT WINDOWS
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 10/16/2009 0:00:00 $764.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo