31A-224 ,-,,,,,,p,
,--`" ' Cori of Northampton 1011 1
` fi r ms. . �,1 , i - _
�� ,' = DEPARTMENT OP t3UILD/NO INSPECTION'S
212 Main Street Municipal Building ,
Northampton, Mass. 01060 r•
WORKER'S COMPENSATION ION LNSUR-ANCI✓ AFFI7)AV1T
I., 4 .. i 4 ) ,c-e 1,...,'
(1i ccus/permi ttec )
. with a principal place of business/residence at:
:V S2.I' ✓) • G,� f / 7 e , none;=) J e l -I 2 - 2 - "1
(s ty /sta>!c/zi p )
do hereby certify, under the pains and penalties of perjury, :hat
01' 2113 an employer providing the following worker's coinocnsation coverage for in
employees wor ng on this job:
A Sf J ttk"feel SAA cLff,.r uc) L-' Z evvt, sy561201 z *9 f / liJ
(las v ocz Cornp_nv) (Po(ic: Nurbcr) (r : Date)
( ) I am a sole proprietor, general contractor or homeowner (ci c:e one) and have hired
the contractors listed below wbo have the following worker's eoDnensabon policies:
(Name of Cont:acror) (In crane Company /PGUc Nnr71b7-r) ( x rilt:on Datc)
(Name of Contractor) (lnsurancc Company/Policy Nurnc^r) (E r,:eon Dale)
(Name of Contractor) (Insuranc Company/Policy Numlxr) (Expiraon Date)
(Name of Contractor) (I-ns - uran CompaEry/PoUey Numbs) (ExPiration Date)
(c tut >dti:: ocil c' -uCI if o< .: to c)cu& inform.x.a oa p trinias to ell 7 co-1)
( ) I amt a sole proprietor and have no one wori- ng for we.
( ) I am.a home owner performing all the work myself.
NOTE: plcs: be ew -r th-t: wick born o iver-3 wbo employ pc to do r , mca •, ; ea-.L-,...c-,00 c rcaau won: m . d..c.11hill or
GO( most L h • ^ t mi in which the bormownor raid.= oc oo the grottodl z t'.en .o tbcdn LT x �->c:11 y e c to to
e- yoloy uoy'c thc..uit.cem _lica Act (GLI52_3zsI rpplic oo by . booica er far c st oc permit ryy c-,4,4- a4 t c
Icbz1 etaau of rn e5ploycr undo din Wo4-40h C.ompooyiioo AoL_
1 undrrrtkod thri a copy of eV, czsicm�i call. b... focwnrded to rho Dino o d
of 1o..srid Aaida7o' Offioc of In. o�.000 for ttm
' covcasc vcrifictioo nad th_t Eiltrc to sc in oovcrn c uodcs 5 2 SA of MGL 152 can Ic.d to the; i_)ositioo of criminal pcatain
oomion of a floc of up to 5 1500.00 .M/ox rnpriioame-ri of up to coo year Lo..1 cavil pco,l;io in t.c focal of n Stop Work. Order rand e
Imo of S 1 00.00 , thy t punt me
1 For dcp,r -tm >1 ti ,..c cell y
- -- - - -- - - - --
Pcrutit Number _
/ Map:; _ I of L
Signa tun: of Liccnscc/Pcrmiace - 3 e _ -
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 1I ev&E% Ice "^ C S 7 O 3-2
License Number
7‘ 1--e r r Ce,� 4- R . 5 -
Address // ,,r' Expiration Date
- - Se`/ - I ZL�I
Signature Telephone
eV.o i,.A2 :, x ,. 0 g; Not Applicable ❑
to 7
Company Name Registration Number
Address Expiration Date
Telephone
SECT` #QN 1O. WORKERS CO PENg..A ION 1N$UR 4FTIDAVft (M.G ° ,L c 52,
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 !K No ❑
aia
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
'"E , ti t x >. AO OF i °0 6 . t ' ,. a . ` *le
New House ❑ Addition ❑ Replacement Windows Alteration(s) 2 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: a old i ' 4 -t b-o-•_ R /' c t 4 ettk d + `ICL- v
1 1 a C ..
l -44,
I
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes ✓ No
Attached Narrative ❑ Renovating unfinished basement Yes ✓ No
Plans Attached Roll ❑ - Sheet IRT'
4 , y as " # :7-1:4 s' }d® �a"
:„1„..,4;,, C . ,.. ��. � e. u�. �.d_�^� , °g
.&n a ... .,,. r .... .... �' a �� � .<�a���3 ..a.
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
SEEfeN 1 . R A ' AO: " ]0 ( To,1� 3C{ 1 ED Wi HEN
ii; � �R WN' Q :, ...., < z� , '&'Pr+� IF� sc PE MIT
I "AA `L "'t' `^ J' < - / as Owner of the subject property
1 P P Y
hereby authorize 44-°1-?' . 4 —/—SP /` "' to act on
my behalf, in all matters relative to work authorized by this building permit application.
. '+ •
Signature of Owner Date
L f
I, 401...- 1 ..e , 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 a r the pains and penalties of perjury.
..47 Print Name /.
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
1 - c) l-\ (r /a ( ��� 1 O t . u y f k Building Department filled in by
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 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 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 -0353
APPLICANT /CONTACT PERSON OLIVER ISELIN
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 50 HARRISON AVE
MAP 31A PARCEL 224 001 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 / /7 X/ Fee Paid lf/ ( / / 7/ V
T peof Construction: REMODEL KITCHEN RELOCATE & REPLACE WINDOWS
New Construction V
Non Structural interior renovations ! 6
Addition to Existing •
Accessory Structure sims -IPMj
Building Plans Included: V 0" , ` I
Owner/ Statement or License 039073 ( I ^
3 sets of Plans / Plot Plan �` , L 1 ►`' �(JC/
THE FOLL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
.4110, , o . .r . n ►, -la
r 0 Ir/
M f uil.i _ Of icia 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.
50 HARRISON AVE BP- 2013 -0353
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 224 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 -0353
Project # JS- 2013- 000560
Est. Cost: $28500.00
Fee: $171.00 PERMISSION IS HEREBY GRANTED TO:
*Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 9365.40 Owner: WEINSIER LAUREN B & STEVEN T
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 50 HARRISON AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:10/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN, RELOCATE & REPLACE
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 10/1/2012 0:00:00 $171.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
50 HARRISON AVE BP- 2013 -0353
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 224 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 -0353
Project # JS- 2013- 000560
Est. Cost: $28500.00
Fee: $171.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 9365.40 Owner: WEINSIER LAUREN B & STEVEN T
Zoning: URB(100)/ Applicant: OLIVER ISELIN
AT: 50 HARRISON AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:10/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN, RELOCATE & REPLACE
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 10/1/2012 0:00:00 $171.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner