24D-320 (8) lit r r2. _
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DEPARTMENT ur BUILOING rNSPeCTIONS —
212 Main StrccL ' Muoicipal Budding; ,
Northampton, Mass. 010G0
NVOIUCL- R'S CONWENSATION tNSURA.NCF AF IZ] AVIT
(li=SC,CJpcnnittcc)
V.9th a plincipaJ place of busioesshesidence zt:
(Sumc.1/6 tyis,2ir-17i P)
do hereby cerufy, under the and penalties of perjury, :hat
( trl am an employer providing dic following \vorkcr's coinpensnuon coverge for Inv
etuptovecs wot{;in,u, on 11Jis job
([nsur-nCx Comcanv) _ (Polio Nunzlxr) (7-pinion Date)
( ) I am a sole propnetor, geoeraJ conta-acor or homeowner (ci_rue one) aid have hired
the contraCors listed below wbo have the following worker's comoens26on policies:
(Name of Contracw-) On-�7urancc Colnpan)'Poiiec, Ntunkr) (1:xp;rauon Dote)
(Name of Cootractor) -- (1J3s-ara_nec Compaov/PoUm, Numt -:r) (Cxpi ;loon Date)
(Name of ColuracJor) (lt>a ancz Com aoyfPoUcy Numbct) (Exptrrnoo Date)
(Name of Contractor) ODsurantx Company/Poky Numbs) (L-"pira6oa Da1c)
(am�ch a&i*6oc3J rtxd if oc. i.n to r. uCk iafona,-•ioa pciaining to.L oco•tfa .�)
( ) I am a sole proprietor and have no one workiDg for me.
( } I am a hooic owner perforruiug all Lhe work myself.
14071::plr—s,tr ewwc Usrr -trjc hoa,-o.cSr_n"t)o ct TplOy pelous Lo d)ry—• �5 cc-� e m cr repair work m r d..ctling of
orK more ilea taro:t:nrir in tsI�dr the bocno"mcr reaido or oo the crvupdT a7psutensm lba-an cv ox C=)r9.11y occsidat,l to tY
employes under the wwka's eospc_rsttiom Act(GL152.n 1(5)),nppU=j3oo by a hovtooaoa for a tica).y:u pcnnit rosy n'id.-not dx
IcSaJ runic of ao employer under dw Workxeg Coa*x=vrioo A.<-
I uodcrrtAnd ttsc x copy of lhij ctatcrocai mry lw for rdod w tbo DcY uta.ad or l..,�rs•w^Wade.•o1Loo or trra—for the
covcrragc vrrZmIioo a.•td Uu(--iJtnc w t4avt coverage under socsioo 25A of MOL 152 on lad to Lh,inz{xnitioa of criaLi,,,1 pcoallic+
oonsi.%i of a rux of up b S 1,500.00 ancvcv 6mpris000)aTt of up W one year Lad aviJ pcn.Jtia 6 LSc roan or a Stop Work Ordc end a
fim of S 100.00 t day ip-mv me
Jc, Y� roc dap✓tn,�a, only —
Pcruvl Number
Signatw,of Licalscc/1)cnnittcc .--T53te
SECTION 8-CONSTRUCTION SERVICES .
1 Licensed Construction Supervisor: _ Not Applicable ❑
Name of License Holder: (�L I v I'rZ s� LC L I�J 103�0-�2
License Number
g —/Jr
Address Expiration pate
r,',' `� j,4-/J , O aril a
Signature r7 Telephone
L
Not Applicable ❑
CA— [0 7 , -Z
Company Name Registration Number
Address Expiration Date
Telephone
SECTION .'0 S,COMPENSATION INSURANCE AFFIDAVIT 152, 25( �
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....... s of 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 yeriod 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.
AIso 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
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemerii Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition[] New
��y New Signs [ ]]6'44,A-Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: /►' y - C•/�-� 64 f+�0 A. Llki-K 1�o aK. 6a,--oioJ
Alteration of existing bedroom Yes '� No Adding new bedroom Yes -- No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll Sheet❑
ticlition"to ezis nit h0-s!;1 co lee t ,fall"`w :
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 hating? 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
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 P,iI penalties of perjury.
Print N e
JJZ/10 3
Signature of Owner/Agent —�Date
File_. MP-2005-0064 .
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center (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 F LED OUT
ee ai
Building Permit Filled out
Fee Paid
Tvoeof Construction: ZPA-CONSTRUCT 20 X 40 DET 4 CAR.GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FqLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94kMATION 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 E,lm/Street Commis ion
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 the Office of
Planning 4 Development for_more information.
10. Do any signs e)dst on the property? YES NO LZ
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO f
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE To
LACK OF INFORMATION.
This corn to be filled -n
by the anildiag Departmant
Required i
Existing Proposed By Zoning
Lot size 2 l
LI �"�o p r v,J r (y)
1
Frontage
Setbacks -frnnt s- ct}- u a ►' /I
- side L: R: 6 j L• 5--R: S—
- rear
Building height I
Bldg Square footage
%Open Space:
Lot area minus bldg U�
&paved parking) Fb /"
# of 'Parking Spaces
#' of Loading Docks
o � v
Fill:
volume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knave e.
DATE: A'�`�' `/, 200 APPLICANT`s SIGNATURE ,..�
NOTE: lasunnoe oT a zoning permit does not relieve an mpplioanYs burden to oompty wttl) of,
zoning requirements and obtain all required permits from the Board oT Health, Conservtstio
Commission, Department oT Pubiio Works and_other_mppliomble Permit granting authorities.
FILE #
City of Northamptonttas�
Ik
Building DepartmenturaCu ��
212 Main Streetewr5st� tt
Room 100 INter/Wl{ xI� � �a
Northampton, MA 01060 �Sefsf�a r ( Rl� rx � . � �Y� i
phone 413-587-1240 Fax 413.587-1272 ��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to bye campltedby o#f�c�
1.1 Property Address:
✓nom w /t✓J. Map Lit tJCaft
Zone 1t614ii Dlstrtc#
Elm St;t)istriit CB Qtst�ct - .-, .. ux. .
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Prin Current Mailing Address:
Telephone
.ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3,- ESTIMATED CONSTRUCTION CQSTS
Item Estimated Cost(Dollars)to be Official Use-Only
-completed b ermit applicant
1. Building (a) Building Permit Fee
.2 rN v • u-�
2, Electrical (b)Estimated'Total.Cost of
Construction from 6
3. Plumbing Building,Permit
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4 + 5) Check Number
This Section F,e Official Use OnI
Building Permit Number: Date)ssu1:
,Signature:
Building;Commissioner/Inspector of Buildings Date
File#BP-2005-0830
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 APP_ LICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid tD
Typeof Construction: CONSTRUCT 20 X 44 DET GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y 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
IN RMATION 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 C ssion
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.
88 ROUND HULL RD - BP-2005-0830
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-320 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: GARAGE BUILDING PERMIT
Permit# BP-2005-0830
Project# JS-2005-0616
Est.Cost: $30000.00
Fee:$132.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sa. ft.): 24219.36 Owner: Oliver Iselin
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:318105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 44 DET GARAGE
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 Sienature:
FeeType• Date Paid: Amount:
Building 3/8/05 0:00:00 $132.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
88 ROUND HILL RD BP-2005-0830
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-320 CITY OF NOR'T'HAMPTON
Lot: -001
Permit: Buildbg
Category: GARAGE BUILDING PERMIT
Permit# BP-2005-0830
Project# IS-2005-0616
Est.Cost: $30000.00
Fee: $132.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq. ft.): 24219.36 Owner: Oliver Iselin
Zoning: URC Aanlicant_Cllver Iselin
AT. 88 ROUND HILL RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:318105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 44 DET GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: T/z9�7-6A Meter:
x'//3103-- Footings:
Rough: Rough: / � � House# Foundationr))-.�- 3 �7•Q�t'�
Driveway Final:
Final: Final: � '�
,�
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0/f
THIS PERMIT MAY BE REVOKED BY JHE CITY OF NORTHAMPTON UPON VIOLATION F
ANY OF ITS RULES AND R.Ek.V.j.ArIONS. _
Certificate of Occupancy, si nature:
FeeType: Dat Paid: Amount:
Building 3/8/05 0:00:00 $132.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo