31A-228 (2) i
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r� `-� )`.,`Q, 01-i-02 of Northampton 1 ==.. �
� • DEPARTMENT OP BUILDING INSPECTIONS 4 . . — . t...... _.
212 Main Street • Municipal Building
Northampton, Mass. 01060 y r'
WORKER'S COMPENSATION [NSURANC'IL AFFIDAVIT
0 , cruscrlpermi ttcz)
. with a principal place of business/residence at:
. Sce 6,,,..,4-_,,-. ) 0 4 / ► ') 4 i) - 1 - Tv -1 ZZ 1
(sat/ciiy /staicJzip) j/U A y c
do hereby certify, under the pains and penalties of :hat
(.liI am an employer providing the following workers coinoenszoon coverage for my
employees worrtg on this job
Al I klititievi'c-c.., P Will e t 3 -°\ - Li
(Uinl_n Corr_ =ny) (Polio: Nu nbcr) (r;°piroon Datc)
( ) L am a sole proprietor, general contractor or homeowner (circle one) amd have hired
the contractors listed below who have- We `ollowiog worker's c000ensa0on policies:
(Name of Co^!:acto-) (Instllane: Coinoi yi?ciie, Num^c:) C=_x irdnon Dnte)
(Name of Contractor) (Ins cc ComoanviPolicy Nu.mcrr) (Lx - nir:uon Date)
(Name of Coaractor) (Ituuranc: C:ompan } •/Pouc h • Numbs) (Expir [ion Date)
(Name of Contractor) (Ilusurano Com pa.ny/Policy Numbs) (ExPirtiou Date)
(eaar?1 s.ddi::ocil ts` acs if at..l.. a -lr) to arc2u3 infocn>s pcstriaing to e11 cocr_c_or-s)
( ) 1 am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: pl=s.. be ew--rc t• wbilc boascowocri wbo employ poi to do r m* ..rr, m-rtrz c, a i,,uu w=rit. oo • d..r11;ii; of
apt =mil— n tVroe 001J in which the botooa ver rai th
d= or 00 e poct.o.d.r z, pu tc _r_ ' tbet'.n ,_c - ax r--.1ty oeei:d. --c 7 to be
Z ployc -t uM,- t v.
he wk.c s ..iea Act (GL152i l(5)), applir -Itioa by e box fart b v or permit n:_y rV ?dC0C the
Iepl rta.'us of na e5ployer under rho Wortic , Compamiiion Act_
1 uo&rx0 and the a copy of hhie rrz1.®cot may v+
y bo forsv<lod to tba Dcporto,00d of Icdur-ri d AL-odoer1 OUo 5o of l_roc.occ for tbo
c oven sc vcrtljcm ioa n.. lh_t L•iltoo to ca:ttrt coon ,c under soctioa 25A of MCI 152 an Icz.d tothe i0rosiUoo of criminal pcutflics
ooaxc¢ia of a fiat of ap to 5 1,500.00 and/or an{uiioamc - st of up to ooc yev LOd 4.7V1) pmrtio io t c form of a Stop Work Ordcr end e
fire of 5100.001 day tptiasl tnc
For tkp..- tm=:11 u..c ally
4 Permit Numbar ______
Signature of Liccnscc/Pc - 3 e
1, , , < �'. ,. � F,. _ . 1, -
1 Licensed Construction Supervisor: r , Not Applicable
Name of License Holder : TI "' � ' LJ 6 ` - 4"' - 3 To . '
License Number
36
J 6,� ice. 40 q - 1, 2
Address ! Expiration Date
PPO- Signature LTelephone
(6
®rE �g:, �,_,,, J, , ..,, .r, Not Applicable ❑
J 0.^^,-4.-- ( 0 - 7 - s / - Company Name Registratio [lumber
g g
Address Expiratio Date
Telephone
ttoo' 'tai!$ ' 4411' ` ud 0 3 "
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 l 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 buildine 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
New House ❑ Addition ❑ Replacement Windows Alteration(s) tY Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: /Z- c A ' 1 e 01 13G7
Alteration of existing bedroom Yes i✓No Adding new bedroom Yes ✓— No
Attached Narrative ❑ / Renovating unfinished basement Yes ✓No
Plans Attached Roll ❑ - Sheet V
°
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
`
y
. §
. S P � ° rig
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& f „ 6 Y �'! A t 4 . - . i",:
1, 'v vl V S.5I' ► , as Owner of the subject property
b authoriz � / f:--3 � _ ��`" to act on .„( my ,i all m tters rel tive to work authorized by this building permit pplic tion.
V 7 LS � ,L
Signat re of Owner Date
6 i. %ce f Lam.
I, , 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 th pains and pennies of perjury.
..../3
, r l .-,
4.
Print Name
......., 7/ Z ' —
Signature f 0 ner /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
All elf 1 ' ;"gyp ' -_ Jk ru C/40-(A.k,4 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 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:
File # BP- 2013 -0103
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 �^ 4 /7O
Fee Paid 0 d G
Typeof Construction: REMODE BATHROOM
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
Illp.ORMATION 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
7 Lc/ Signature uilding Offi ral 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.
28 HARRISON AVE BP- 2013 -0103
is #: 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: renovation BUILDING PERMIT
Permit # BP- 2013 -0103
Project # JS- 2013- 000158
Est. Cost: $11600.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft): 8973.36 Owner: MARGHERITA ANTHONY P & DEBORAH BERNARDINI
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:7/26/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
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 Siunature:
FeeType: Date Paid: Amount:
Building 7/26/2012 0:00:00 $70.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner