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Q� DEPARTMENT OP BUILDD\IG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COi1'f�'ENSAUON INSURANCE A 'MAVIT
with a principal place of business/residence ate
(mi�-IJci�f/nalcia p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following %vorl:cr's compensation coverage for my
employees wormy, on t�lis job.
(Irinlran� Cor�p`��) (F'elic�Number) (i=.zpirtion Date)
( 1 I ?IIl a sole pronne g'en`eral contractor homeow-ne; (c cie one) and have hired
ti
the contTactors hSted below who have the folio)WU' g worker's compensation policies:
.. J"� V YL 7i5 r�l L- -- I ') tl � J- 1./_ U1 LX1 N'& _ / " l--
(NIme of C/on!mctor) (Insumnoz Company/Polic' Nunle:) (F-xpu-noon Date)
(Name of Contractor) rwc:, Company/Pollc-v N=t-�-r) (Ex pitation Date)
(Naive of Contractor) Rnsuranc Compan}•/PoUc Nutrl= ) (Expir-uon Date)
(Name of Contractor) (La!;u nce Company/Poh y Number) (Expiradon Date)
(mach additional sls cL if noocnarf to mcluci-i Ibnniti oo penni=ng w ell ooatT Cc o.^3)
( ) I am a sole proprietor and have no one wor4 ng for me.
( ) I am a home owner perfon=' g all the work myself.
NOTE:plrsc be aware thz*wElotho�axoYmc�n who crnploy paiom co do aixzjtca, acr,co es^sc oo Cr rcpau worX on a d-Tiling of
aot mom than Lhtoo unitt La wfnch the rYomoowuc rcmdc3 or oa Lbc g viads dppUILG1 i th> c o LT Do( a-,L4 oOCS:dc'IVd ID t)C
cmploycr3 t,IY1CL the vexk&-i c x mpcsatim Acl(GL152,=1(5)),appticz6on by a homcow-jcr fcr a license a permit M-y-i&aoc the
Ic$il rtshia oCan omployer under tho Wortco��Compomalioa Ad
I undcrv3 d ttvd a copy of Lhii ct rcmraI may bo fory�ded to tbo Dcpnrtmr>t of Cffioo of io u--for th-
ooventgt vcrificxtioo aad that L•hxc to secure covetagc trader section 25A of MGL 152 can lc d to Lhe unposition of aimiaal pcitnitia
ooau:a g of a fine of up to S 1,500.00 and/or cnpriso® of up to ooe yCar end civil pmnhim in dx form of a stop W or?;Order and a
rim c(S 100.00 a day tg&u t me
For 6,7-'tz>r —drily
Permit Number
2A1 P Lot n
Signature of Lic=sc,J- crmittcc lie
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address , Expiration Date
Signature Telephone
9 Re>7ws e�recimcr�ement Contractor° " h� ���� an . .��r. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone JS r 2 Z t'
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...... ❑
m►�a►� nleraemptori
The current exemption for"homeowners"was extended to include Owner-occupied Dwelliny-s 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) Sil*"- Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: N&"J �`'�^'°�` 5 �'� n r r`rt t f„frfl r•-� 1 �v �-' v���,,rL_
Alteration of existing bedroom Yes No Adding new bedroom Yes `�No
Attached Narrative❑ Renovating unfinished basement Yes -_�N o
Plans Attached Roll ❑ - Sheet o"'
sa-. If t e [ o aii+r�o�additid to zcs ingg ho�siing: corripi'e ii .#olio in
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?
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'
►, An lznkxty as Owner of the subject property
hereby authorize tllXl/e 11� to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 the pains and penalties of perjury.
Print Name ,%'
- 1® ' 1
Signature of Owner/Agent Date
i
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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
1 L /rc/' a w C r-v tt 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:
y.
City of NDrthampton
'Id epartment
D U
in Street
100
�ha , MA 01062
` 0n 13.587-124 Fax 413-587.1272
R
BuIlLIJInu 11—
A PLICA Tco R, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION t1 -SITE INFORMATION
1.1 Property Address: This sectott Ito be completed b offce
r � r
C 1-t L A r� E Map �f dot R" 111
Elm St.F)EStricf Ct3:District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
PA ry LrCnJ a.c t4 �
Name(P ' Current Mailing Address:
( 4"Mki" Telephone
Signature
2.2 Authorized Agent:
C)L l vC-rt- 64-IZ-
Name(Pr Current Mailing Address:
J''r L/ z z y
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical �Q (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 6 Check Number d d
This Section For Official Use Only
Building,Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0663
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center (413)584-1224
PROPERTY LOCATION 21 BIRCH LANE
MAP 36 PARCEL 211 ZONE SR
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 WINDOWS,KITCHEN CABINETS&FLOORING
New Construction
Non Structural interior renovations
Addition to Existing
AccessM Structure
Building Plans Included:
Owner/Statement or License 039073
3 sets of Plans/Plot Plan
I HEFOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedibased on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § —w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § —w/ZONING BOARD OF APPEALS
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
/-,30
Signature of Buil g Offici 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.
21 BIRCH LANE BP-2001-0663
COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 36-211 CITY OF NORTHAMPTON
Lot:-001
Permit: Bgilding
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0663
Project# JS-2001-1 194
Est.Cost:$16500.00
Fee:$60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq.ft.): 77972.40 Owner: LENKOWSKI PAUL&ANN
Zoning: SR Applicant. Oliver Iselin
AT: 21 BIRCH LANE
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:11301010:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WINDOWS,KITCHEN CABINETS &
FLOORING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/30/010:00:00 9902 $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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BP-2001-0663
COMMONWEALTH OF MASSACHUSETTS
.. ock:36-211 CITY OF NORTHAMPTON
Building
:Non structural interior renovations BUILDING PERMIT
BP-2001-0663
JS-2001-1194
10%UPO PERMISSION IS HEREBY GRANTED TO.
00 L 3 ss Contractor. License:
_ Oliver Iselin 039073
A):): 77972 40 Owner: LENKOWSKI PAUL&ANN
► Applicant: Oliver Iselin
--� _ A?`: 21 BIRCH LANE
P 'tAddress_
Phone: Insurance:
'ce Center (413) 584-1224 Workers
ation
a WMPTONMA01060 ISSUED ON:11301010:00:00
RFORhI THE FOLLOWING WORK:INSTALL WINDOWS,KiTCHEN CABINETS &
�. G
POST TES CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings,.
Underground: Service: Meter:
Footings:
Roug Rough: �\','� �� House# Foundation:
Final 67W
Final: (o O
Rough Frame:
Gas 411 Fire De artment
Fireplace/Chimney:
Rough: Oil: Insulation:( $' 9 -5-01>4z
Final: Smoke: Final: 0,T
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc
si nature:
Fee e: Receipt No: Date Paid: Check No: mou
Building 1/30/010:00:00 9902 $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
` ' � �a:achusetts
of Wart4amptan
$ effirt of tht )nsptrtor of Puilbings _° W
212 Main Street•Municipal Building -
Northampton, Mass. 01060 �.•r
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CERTIFICATE OF OCCUPANCY
MARCH 20, 1987
Page No 36 Plot 77-12
Building (Name) NEW SINGLE FAMILY DWELLING/GARAGE Address LOT #12 BIRCH LANE
Owner DdN QED- Address
Applicant DClUG FERl2ANIFISKYLINE DESTGN Address h BOX 149 FLCRENCE
Use: 1st RESIDENTIAL Occupancy
2nd Occupancy
3rd Occupancy
4th Occupancy
Zone District SR
Required Inspections:
New Building X Existing Building
Elevator Electrical
Plumbing �- -o Fire
f GAS: Other
Building
Inspector of Bullclifigs