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� - �� 1 • ' DEPARTMEIJT OP BUILDING INSPECTIONS i 4
212 Main Street ' Municipal Building
Northampton, Muss- 01060 r'
WORKERS COMPENSATION INSURANCJL AFFIDAVIT
VL,J%/
_ _ .
(li txnscc/perrni ttcc)
. with a principal place of at:
3 6 sue- ✓' e.' C rt.- -- 40. . hone:' ,S (.2
(stTc deity /statc/znp)
do hereby certify, under the pains and penalties of penury, that
( ) I am an employer providing the followine worker's cotOoeOsauon cove:mgc for Iiw
employees wor ng on this job-
s
4 - f a . ( vhf...r4 --c.4._._ W L+,f 3 4) 1 41 e 1- f 4∎ I 1 `7
(Lnsurncc Company) (Policy Nambcr) (r• Daze)
( ) I am a sole proprietor, general contractor or homeowner (code one) znd have hired
the contractors listed below who hive the following worker's com,ensanon policies:
(Name of Co.n.zracto-) (tnsumnc:; CoinoasnyiPoi1Ci Nurnk) (i.x)inmuOn Ditc)
(Name of Contractor) (Insurance ComoanviPolicv Number) ou ton Date)
(Name of Conrraeto;) (Insurance Company/Pot;cy Nambu) (Egpunoon Date)
(Name of Contractor) ( Losurance Company/Policy Numbs) (Expiranoo Datr)
(aaat addi;;or1 c'xG if nooc-iuy to utcu& iofora._'ion pertn.inin.6 to .11 ocor_co:- )
( ) I am a sole proprietor and bave no one working for me.
( ) I am.a home owner perfornaing all the work myself.
NOTE: plc= be aca' chi u-tii b ocoa -ocr) wbo employ pczon3 to do Ica= -'ooK, cc-v-.:c-J c 1.,...tu work oo , d..ctl i; of
Co( r.Xoec tl::. I.c vnf,J in u5eb the b noo ocr roida or ca the grouod.1 appurten -r: tbc-ao -o coo( t,� c.11y occl:dscil to be
oorployc undo Ibc..ockrr'a oa:cpcntioo Act (0L152 o I (S)), npplicsticc try a bo9ooava fc:: 1.)--,,, o permit rr_•y cvitcocc lb.
I cs.l nano of oo r_t: r, l o yor uodc, tho W or*oe. Coa poc o.iioa An _
1 I u.odc. - rz.nd tha . ez >� r-wivd
copy of th . loa ca.y b. food to tbo Depot rr,,o r�A Arod
of 1rsrhd cr11 OCGoo of lraw.noo for ti). oo vcntsc vcriGctioo end that L-iltrt to cocurc co'.xrabc tndcr sccuoo 2S A of 'IOL 152 an Iczdtotbc i xiz;Iioo of criminal pcwltics
comisti.-1.8 of & floc of up to S 1,.300.00 and/or fr c oorvcyc of up to one yc:r Lod cavil pm,ltio ie tc form of a Slop Wort Order nod .
Piro of 5 l00.00 t thy tpunt ac
For dcp..-tnr_ =-1.t uK ooiy
____(.9_________ ` k N ttmt>er
1 Map:: Lot -
Si Gna tttrt_ of Utccnscrli'crmittcc �t6- _ -
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : VC-1 SSE t.) .-I Q 5 0 7 -3
License Number
.fi _Ito- iit 4,4,- CL -►-,f- It 17. N 'To" q - lS - iv
Address Expiration Date
fft /- 1Zig
I/ Signature ( /f Telephone
J. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
cr - 7 - I °
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 Exempt
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 D Addition Er Replacement Windows Alteration(s) Roofing 0
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [O] Other [O]
Brief Description of Proposed l� l i 6„ e k We—) r Ci.ee a( _s^-/%,,:•,.d0-
Work:
Alteration of existing bedroom Yes •/ /..--- No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll
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 Cfl sit STo rI4E,4_ G t , , as Owner of the subject
property
her - gut' • rize th ..1.TE �i—
• act on behalf, in al atte - relati e to work authorized by this building p= rmit - • lication.
gnature of Owner — Date
l
-1-1,76/ t ' 1 - 3 . ( - ) r , 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 pains and penalties of perjury.
--- d►
Print Name At
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 144s N
Frontage Z 1
Setbacks Front 1 d N L
'g
Side L: R L: $ R: 70 r �
Rear
Building Height J' t f
Bldg. Square Footage 34. % p y
Open Space Footage
(Lot area minus bldg & paved 74' 34
parking)
# of Parking Spaces Z '
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO er DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 a DON'T KNOW Q YES C
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO ef
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO er
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department °use only
City of Northampton Status of Permit
Building Department CurbCut/Driveway petit
2'12 , Main Street Sewer /Septic A flit ,
Rom 100 W°ater/1(hleli Availability
Wottham ton, MA 01060 Two Sets of Structural Plans
phone 413: -58 240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
C14 t 1 T O P i4- C k- e3 L--r-1 3 ►°`'� a "'� � /� ' 1./ � ` �-o, J
Name (Print ) Current Mailing Address: z 6 lJ
Telephone
Sign
2.2 Authorized Agent:
4-1-a d, J t; J i ✓► t:. U C n Tv
Name (Print) Current Mailing Address:
7 1 1-, / w I11.1
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 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection r-
6. Total= (1 +2 +3 +4 +5) Z 1 Check Number e
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File 1P BP -2010 -0489
APPLICANT /CONTACT PERSON OLIVER ISELIN
ADDRESS /PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 3 MONTVIEW AVE
MAP 32C PARCEL 284 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL NEW BACK DOOR & STOOP
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
INFOyMATION PRESENTED:
pproved 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
Signature of Building Official 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.
ae Fle
BP-2010-0489
Is 4: COMMONWEALTH OF MASSACHUSETTS
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 -0489
Project # JS- 2010- 000676
Est. Cost: $2970.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 4878.72 Owner: GOLDEN CHRISTOPHER D
Zoning: URC(100)/ Applicant: OLIVER ISELIN
AT: 3 MONTVIEW AVE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:11/6/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW BACK DOOR & STOOP
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 11/6/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo