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DEPARTMENT OP BUIL•DrnC I'NSPECTION'S —
a
212 Main Strcct Municipal Building
Northampton, Mass- 01060
N-volucc.WS COI Q'ENSATION MSURANCE A < t ANfrr
(L ccuscclperml ttcc)
with a principal place of busi.oess/residence at:
(sta CWCi ty/stalcrz�p)
do hereby certify, under the pains and penalties of perjury, :hat
(�I zrn an employer providing the following worker's coinocnsftion covcMIc Cor Illy
eluployces wor�Jng on tills job:
(tasuj o Corar m\') (POLC—,Nu r) (Erpirz or, Datc)
( ) I.am a sole proprietor, general contractor or. homeowner (ci:c;e one) znd have hired
the contractors listed below who have the fobo%ving worker's rampenvation policies:
(Name of Contmaor) (insuranc Comoan}rTciic; Num^r;) tEx—�)i •auon Datc)
(Name of Contractor) -- Qsls-a ancc CompanyfPolim• Numcrr) (i✓xnimuon Due)
(Name of conaacro,) (tnsuranc:CompaDyfPoucy Namlu) (Expiraoo Date)
(Name of Contzacior) (Irasuranc—c Compwy/PoUcy Numbs) Zt�isvtioo Dart)
(&M c6 additioc3d c'.xa if c-s
ocoiry to xtc u�idorm,.aoc pery.iaias to aL oca�—con)
O I am a sole proprietor and bave no one working for me.
( ) I am a home owner performing all the work myself
NOTE.:pl=-sc be ew i-C(L'NQ-.bcc ON4Mcn Nbo Cpl%peeom w ocr--,.:;C ,n cr rrpatr`a'oric ao a cl-tU�- g of
oot magic th-t'-nr_tmrs in wbids the bomoowDcr r=6=oc oc Lb,p mxu zpp�utensr tbc-co�T ox G=W-lry ooerid--od to be
cv ploycn uorSc Iba O=apc-,s_voo Act(GLI52s31'(5)1 application try a homoouma for c l _oc polah—y-idcooc the
Icgal ctza.c of ca c loyor uodcr'dw Wocirolc Cocap,,L. oa AoL
f uvdcrt od tba a copy of a j,rn.tcmmt c.y bo focw_-ded to tbo pc�of Job icJ Aca&o Offioo of Lz 000 for tho
oova-xgc�Cafi:sioa and thn.t L•J='C w saxuc oo-- [ uadcr soaioc 25A of Mot.152=lad totlx im;r�itioo ofaimiWJ K-i6c
000siFmg of a riot of up w S I}00.00.rtdror*ri*mz=-A of up woo-yr:r e.od ci i pour,in ex form of a Stop Work Order rind.a
rim of S 100.00 c d_y cpiait cy-
Permit Nturtbcr
Nip;;^ I.ot
S19atun of LioaascclPcnruucc
y
N
1 Licensed Constr coon SuR v'��r: Not Applicable ❑
Name of license-Holder: � ' cL E�- i--� ()3 0:�
License Number
Address
�T Expiration Date
Signature Telephone /
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
a.�
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...... ❑
The current exemption far"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 faun.
structures.A person who constructs more than one home in a two- ear riod 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 persons)
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 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
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:
KO
New House
D Addition ❑ Replacement Windows Alteration(s)El---
Accessory Bid . ❑ Demolition❑ Or Doors ❑ yq J'x 6'V
Roofing 13
New Signs [ ] Decks
[ � Siding{ ) Other[ ]
Brief Description of Proposed Work: 'A-
Alteration of existing bedroom Yes ,/
Attached Narrative D NO Adding new bedroom .
Plans Attached Roll D. Sheets Renovating unfinished basements r —Yes No
No
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
L Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodpiain 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
I,
V " Cz '`� , as Owner of the subject property
hereby authorize 'j T& to act on
m behalf, i all matters to work auth ze y this building permit app ication.
z� �o G
gnature f Owner D to
as Owne ' e
ereby declare that the statements and information on the foregoing application are true and accurate,to the st of-my
nowledge and belief.
igned and r the pains and penalties of perjury.
rint Name / y /0-6
ate
gnature of Owner/Agent
....... ........ .. . ..............._
y arty of Northampton
-Y---- y (ding Department
r - 12 Main Street
U Room 100
Northampton, MA 01060
phone.413�874.240 Fax 413.587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
b
1.1 Prope!U A—d�7dress:
-13AJ�-� 6-v�
7'��Ng ,z gg r"
a ., 5
2.1 Owner of Record:
1/ ✓( i- ) X66 6J f �.
Name(Print) Current Mailing A dress:
Telephone
0i ure
2.2 Authorized n :
I I<- z 1 26
Name(Print) p� Current Mailing Address:
l de`> -/ ? z-
Signature Telephone
Qom, «•�
Item Estimated Cost(Dollars)to be
completed b rmit a licant
x
1. Building
2. Electrical
'?yo+
3. Plumbing
a
4. Mechanical(HVAC)
5. Fire Protection '
6. Total =(1 +2+3+4+5)
File#BP-2006-1136
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 88 ROUND HILL RD
MAP 24D PARCEL 320 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyaeof Construction:_FINISH BASEMENT SPACE
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
INF IkMATION 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 Co n
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.
gg; BP-2006-1136
GIs#: COMMONWEALTH OF MASSACHUSETTS
320 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1136
Project# JS-2006-1684
Est. Cost: $6950.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq. ft.): 24219.36 Owner: ISELIN OLIVER&DEBORAH S OAKLEY
Zoning:URC Applicant: Oliver Iselin
AT. 88 ROUND HILL RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:51212006 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT SPACE
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 5/2/2006 0:00:00 $50.001709
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo