38D-034 •
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A� ti Eit of Northampton 1 lir—
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g �4% vl► ' E �lcsenchnectte 1=
DEPARTMENT OP BUILDING INSPECTIONS —_
212 Main Street ' Municipal Building
- Northampton, Mass. 01060 ' IMO ,.
WORKER'S COMCPENSATLON - INSi"TRA.NCE AFFIJ)AVIT
L Ot ) v(?( t z L ,,l .. _ _ .
Qi ccuscriperml ttcc)
with a principai place of business/residence at:
6 ft ,e c C C rif.;` - Jo•e7 •"gt VM (phone") ( 1 1 i - , ST Y - I • L `9
c (strc ;t/ci ty /statciz i p) 0 1.0 6
do hereby certify, under the pains and penalties of perjury, War
( am an employer providing the following worker's coinoensario; coverage for lily
employees worng on tins job:
G 71 . � S'3 3 /8?v 7- — - 1t
(las . -- o Coonan (Polio: Number) (epiruo n Dare)
( ) I am a sole proprietor, general contractor or homeowner (ciucie one) and have hired
the contractors listed below who have We following worker's comoensa policies:
(Name of Contmcror) (lnR rancc Company /Fancy Nlurl!YT) •(i_\ )ir Ji.on Date)
(Name of Contractor) (Insurance Company Policv Ntrmccr) (E4i_raiion Dais)
(Name of Conracto,) • (Insuranca Company/Policy Nnmbu) • (Expiration Date)
(Name of Contractor) (Insurano Comcauy/Policy Number) (E.Piration Date)
(aa 'A'kt:oeal cxca if oec-csrry to asesud , foetoaEoo pertaining to all ooar..c.oa)
( ) I am a sole proprietor and have no one worlang for me.
( ) I am.a borne owner performing all the work myself. -
NOTE: p1=-s: be awor< t!sci u { J bococov.vera wi>o employ pczaas to do r- .=catz,^a., cc- - ,;c, o c repair ..orx oo a d' dfl:g of
co( mocc th --2 O loo tmifs in wh cb the bomoowocr mod= or oa the groans app rrtcn-r= tbccto arr to g<- c: -..Uy occ:diczi to he
. - - tployc - s riy'r the' d t o ' S c cro iioo Act (GL152_5.1K5)), :.ppfit tion by a bocnooauca fare Lc-^, cc (cant ar..y O'idem t -c
Iap.] n0n,< of an •_-a.,rloyer under 'alto Workzet Coonpo o-dioo Act_
1 I undo rt.io o a -- ca.
d th copy of thi. c`zy bar. forv ied to tho DoprrtLoad oo of Lorid Ad'" ff o oa of 1 .. , ' - ''“>.°
fe th
foe
c avc,-isc vtrif cz.i and Uvt f_iitac to scauc covcntgc =dm- soctioo 25A of bIOL 152 can Ivd Loth: ioEhon of crimiatl pcwllics
000siaiag of a fine of up to S1.300.00 and/or troprisoom 1 of up to one yczr ead aril pm,Itia in tx form of a Slop Work Order end a
nit, ofSI00.00a thy ogainon
For dcpc-tm =: sr u,c only - - --- -- -
-_
. -r I z3 f II Permit Ntunlxr
----� i Lrp:; _ L ot . ". — \
• SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder : C ✓t JJ L O 'f 7
License Number
2i V14vi C .� '• 1" .. , .
Address 6,2 r Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
/ ?Sze
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 tB' 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 buildinz 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [Dl Decks [Q Siding [D] Other [0]
Brief Work: Description of Proposed t IP ,1"i ` 1 _, n pi G- , i j rt. c: J-} foop "f c.s
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, SA /411) ✓ ' Cry e r A / itfirE JJ - Je<r , as Owner of the subject
property n
hereby authorize 4 t C£i-
to ac n my behalf, in all matters relative to work authorized by this building permit application.
( gOkliV OA-c ,S J' I i 1
Signature of Owner Date
I, 21 l a ` ) t , 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 unde t pains and penalties
�
nalltiies�of perjury.
di /
Print Name S / -.?
Signature of Owner Agent Date 111
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning p This column to be filled in by
N I 4p.i G fr j ,1 4- __17),,f 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 " 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 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES Q NO
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 eJ
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.
n•7�
��l' DePermpart t ment use only
� • City of Northa ► •to tus P r mit:
5 ;� wilding Dep• ' m= t f' fr t/riveway i
Q 212 Main rtS of t e is Ava ability,
Room 1 00 ter > :II Availability
Q� rthampton, M A 010 wo - ts of S tru cturalPl plans
�; 413 587 -1240 F ax 413 -587- Ks ite Pan
i
1 ' '' 04, • or Specif
i : ,
C TO C ONSTRUCT, ALTER, REP AIR , RENOVATE OR EMOLISH A O NE O R TWO FAMILY DWELLIN
SECTION 1 -SITE IN
1.1 Prope Ad dress:
Th sec tion t Ise completed by o ffice
t it ��.,J �] k Map Lot Un
f �" Zone Overlay District
Elm St. District CB Dis trict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZ AGENT
2.1 Ow
�,�nl mil ��T, ��
�� rC-
ner of Record: t� l—� LSP.� �'C.w...t-
Name (Print) Curre Ma iling Address:
S v ~ — Te lephone
Si ature J
2.2 Authorized Agent: �^
l I i LI �(e I .J .7 6 f ✓► C G &IV t /Z 1?
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS CT 4....... 7),..„)2___
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building �c�t
(b (a) Building Permit Fee
2. Electrical ) Es timated Total Cost of
Ci from (6)
3. Plumbing - � Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protec
6. Total = (1 + 2 + 3 + 4 + 5) j (0 . Check Number ,,)3 � ,,'b
This Section For i al Use On
Permit Number: Date
g ssue
Signatur: � .5- 3 H
Building Commissione /Insp ector of Buildings I
Date
Building
23 HARLOW AVE ' BP- 2011 -0985
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D - 034 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 -0985
Project# JS- 2011 - 001610
Est. Cost: $3980.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 4486.68 Owner: GUPTA SANJIV
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 23 HARLOW AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:5/31/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR PORCH FOOTINGS
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 5/31/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner