38C-051 4 -(lw -1)
ti
• R � .. tick.. o (yrf of �orf! nipton 1 — ._____ ` �Z a�snc h n�c ff a t- .
• � ' DEPARTMENT OP DUILDDDG INSPECTIONS
212 Main Street • Municipal Building
Northarnpton, Mass. 01060 r
WORKER'S CON PENSA'z7.ON LNSURANC1.E AFFIDAVIT
�� I it(-.. J 1 LL.,,J
(1i ccuscrJpermi ttec )
With a principal place of business/residence at:
t le" "1 G-- 4-1.- Ail , r °4 hone q . S - j - I l Z--"/
(strc I/ci ty /stalclzi p )
do hereby certify, under the pangs and penalties of perjury, that
(✓)' am an employer providing the following worker's coinocnsa:ion coverage for illy
employees working on this job:
CeA4.4,r,- I . hr (") G i 2 1r'it-/I2— . - 1 0 1 (
(Insur - ;moo Coot =r,\') (Policy Nu r) (r:.-p1rtfon Date)
( ) I am a sole proprietor, general contractor or homeowner (dole one) and have hired
the contractors listed below who have the following worker's coioensa pol!cies:
(Name of Contractor) (Inn!rancc Cotnpanyi:'oiie; Nu-ail (1= Xpirdtion Date)
(Name of Contractor) (Instuancc Company/Polic Number) E et notion Date)
(Name of Coacactoi) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurano Comoacy/Policy Numbs) (Expiration Date)
(ea3c± •rt'tr oclJ r'xct ifnc�, r, to ow_. infoc r oa prstzin; ns to all oocrr.- r --o:
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE.: plc.sc tx nw:trC 0 wizic 1x ov.om wt>o employ pc ro d) �.s• c Z"- - ,:c�0ct c rrpair , vora on . d..cll- E of
not mote thr..c t noo tZ1fi in which the bo xxr,ocr rrvdo oc co tb.c grouodr zppuiyrti:.r4. tbcr.n c..r nx Cccrnily «mid... - -rd to be
--tpioyc its the k'oc I i oea +.im Act (GL 152..a 1(5)), .. pplir - bye bommava fare tics, oc po - tna rn.:y cvidrncc t.hc
I ctaau of an csyloyoc undo ho Workco(a Compocr ti-o Act_
I up-day t c copy of this ctat osay bo for-v.-girded to the Dcporluooi of loautr An:
id Aodcct! Ofrioo of b .c - .00c for rho
c ovaa.sc vvific iioo tM th-.t f:iltat to sowrc coverage tnsdcr soctioa 25A of MOL 152 can lad to i_ oositioo of crimiaii pcwhics
coos uing of s fine of up to S1_500.00 ux1loc of up to <oc year tad civil rmattio , dtc form of a Stop Wort Order end a
rim ofS100.00& city r • ax
.j'F Fa dcp..-tm� -iJ u.c Drily
Ptrmtt Number
SECTION 8 — CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : OL- 1 ✓ e-ft [. ^f _ i ti 01509,2
License Number
(--. i
_ .e____________ Address Expiration Date
s�N �� - /Lz`�
Signature Telephone
9. Reoistered -Home Improvement Contractor: Not Applicable ❑
/v ..at
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[J Siding [D] Other [D]
Brief Description of Proposed
Work: Ye G � r kV° �G c � / r lei., , ! ( C r '� '° `� G'l Qu er n w c_. �e
Alteration of existing bedroom Yes 'No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll - 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
I, ' " ` � � d , as Owner of the subject
property ---/--/0 s,
hereby authorize ' " r Lam`
to a t on my behalf, in all matters relative to work authorized by this building permit plic ion.
nature of Owner Date
` ' �I_ �' n
'7`4' ' 1 6 -P3 c — , 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 p ins and penalties of perjury.
Print Name
I IN 11l /I
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
I ( ) This column to be filled in by
// 1'1' "Qn p i — �,��� �, C (�C te.( 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 a 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
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
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 Q NO er
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc vation, 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.
N f
r Department use only
City of Northampton Status of Permit:
Building Department Curb CutiDriveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Ultell Availability
Northampton, MA 01060 Two Sets of Structural Plana
phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plant
Other Spec' 1
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH , •N: OR TWO FAMILY DW: LLI G
X2I2011
SECTION 1 - SITE INFORMATION
1.1 Property Address: This s - do • +;'= �''Y 0 $ice
3 S fvv. 1" I clk le -r C .. Map Lot •
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r �
Name Print) Current Mailing Address: j20 _ ,s-9 .- } 1 5
11101 Telephone
• . ure
2.2 Authorized Agent:
t e [ fe' /,�.. 2 b fP_ rv, -t.4 f 4-,,- . 4 Name (Print) Current Mailing Address:
.1 L i — 1 , / ` ZZ i
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
2. Electrical (b) Estimated Total Cost of
- ' Construction from (6)
3. Plumbing Z.. Building Permit Fee
_
4. Mechanical (HVAC)
5. Fire Protection if :20 . ? c
6. Total = (1 + 2 + 3 + 4 + 5) & 1 • ;15 Check Number p --
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: _----. y i / 11
Building Commissioner /Inspector of Buildings Date
35 SOUTH PARK TER BP- 2011 -0836
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38C - 051 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: WATER DAMAGE BUILDING PERMIT
Permit # BP-2011-0836
Project # JS -2011- 001384
Est. Cost: $6900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ISELIN WOODWORKING
Lot Size(sq. ft.): 7187.40 Owner: DAWSON THEO L
Zoning: URB(100)/ Applicant: ISELIN WOODWORKING
AT: 35 SOUTH TER
Applicant Address: - Plzone: Insurance:
36 Service Center (413) 584 -1224
NORTHAMPTONMA01060 ISSUED ON :4/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: repair and replace interior partitions damaged by
water
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
//
Underground: Service: LS Meter:
Footings:
Rough: Rough: 11 a ) ) House # Foundation:
� � Driveway Final:
Final :,y,, i -- -
( ..N4 Final: -„ t ‘ / �
Rough Frame: 0k 1 1'x 2 1 "
Rr iv, OK 4- (g c vim--.
Gas: Fire Department Fireplace /Chimney: '/,
Rough: . " irk/ Oil: Ins_ilaticn: }A S t t C YO-S" - itiCittn.
Final: J ( moke: Final:QK . 1 Q N
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU ATI N .
i" 11 :444 : 1 go' tzet6
Certificate of Occu anc V signature:
p ,,
FeeType: Date Paid: Amount:
Building $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
6.