44-113 2 ecc3.a yF ;—_
(yrf Of �n�tfjal�l}�tOil
4 A E ,Q1c5anc11r: c I f 0
DEPnR T MEN'r OP QUILDP\IG INSPPCTIONS
212 Alain Street ' Municipal DmId)n0
Northampton, Mass. 01060 -
`VORl•MZ'S CONMENSAT'ION MSUTZA-NCF AFI'DAVIT
(liccuscxJfx-rm�ttc�) _ _ .
�>r�ith a pl-il�cipalplace of businesslresidence at. ���
b ler--V "re all ��, )ore;: 5�1'`� 12 2
(svf---t/ci tyiSI,uc'zj P)
do hereby cent iy, Linder the pains and penalties of perjury, lh?n
(�l un an employer providing the following worker's coinncns_-1 on cove; ^,c for my
etuplovccs wor-,jllg on titis job.
([ns11I":nCr Conr L.v) CPclic-; N"u-m?^r) (- pinion Date)
( } I am a sole propr;etor, general conmacicr or homeowber (circle one) and Lave hired
the coouac ors listed below who have the follo%viDP_ Worl er'S caODen non policles:
_- (Nnmc of On-�L;"IIG:: I,OIlIUa.,i}'i �GL'C�
(Dame of Cootractor) (Insuanc Comoan`•iPoLc-, N'umil-zr) Date)
(Name of Coanactor) (lnsuianc i Compan)•/Poticy Numb r) (Expir uon Datc)
(Dame of Contractor) (Lasurancz compan-y/policy Nluatr r)� (ExIm-aLmi Datc)
(atlae+,abd::;oc�1 c' ct to. -'uci-uafocc�y'i oo�CStrya:sue to ill ecar-r' '�)
O I am a sole proprietor and have no one wori3ng for me_
( } I am a home owner performing all the work myself.
N07I:ply.:be cW-zr coralay o!
no(mom th-n L -L,.j in , ;cb ttx re e-=oc oa the to b
cz loyc-3 unr c Lhc wo-, ti:occ�:ico Ac(GLl52xs 1(5)�:pptuatica iry n ho-mcot*x fm c U=---cY prnun rr::y c�'Td X tt'c
lc J n=^«of nn—sloycr uodcr dw wok. ',cocnpacn�rice_
I undcm and dw A copy of this c>tcmmt—ty bo focwnr i d t.o 0 Dcputz c of Icx'su.ricl nmdcs..f Offioo of Irrwzoco for tho
coven sc vcrific iioo an8 tlu U-u-c to tccarc cov-mgc ur do soc on 2 S A of MGL 157 c o Icxd to tb L-,T t oc of c vein l p na l c
000sirin oft fin,of up W S 1.500.00 end/cx ir {auoacnc of up Lo o«yc.r t-:1 c.,-%-d Pco�p,O in tic form oft Stop Fork Ordcr er-
fina of S 100.00,day cFpi,�crx 1
For d�T;.•tn,-:.�s u,c oni).
6� PcTm t i fumbcr _ _--
Sit;oahlrc of Liccnscr/I'ctmittcr_ ��3Ce
t
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ✓ �I S�? U '3 1 c 7-T
License Number
Address ; Expiration Date
Signature Telephone
Not Applicable ❑
Viz-&
Company Name Registration Number
Address Expiration Date
Telephone
f.0114
0 �3 .
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....... Er' No...... ❑
The current exemption for`;homeowners"was extended to include Owner-occupied Dwelliinus 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
MAO
New House ❑ Addition ❑ Replacement Windows Alteration(s) V' Roofing ❑
Or Doors ❑ -
Accessory Bldg. ❑ Demolitions] New Signs [ } Decks [ ) Sliding[ ] Other[ ]
Brief Description of Proposed Work: . i t e
Alteration of existing bedroom Yes �No Adding new bedroom Yes `�No
Attached Narrative❑ Renovating unfinished basement Yes N
Plans Attached Roll❑ - Sheet IH�
VAN
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
of - -
G�c Z f p e_j�_
l , as Owner of the subject property
here qehalf, orize
i e x,I C, to act on
my Mmla ve to work authorized by this building permit application.
, 7
Signature Owner Date
rrv✓'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 and r the pains aDapenalties of perjury.
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
i 9
'�y y _ / -) ) This column to be filled in by Y
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:
City of Northampton
Building Department
JUL - 12014 / 212 Main Street
Room 100
Elect-ic. Plumbing&Gas inspections Northampton' MA 01060
Northampton, ArA 01060
hbWe 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING.
S: p .w.i T.,. .MYluiN�?` Y°,^t,#..A.f ', -
1,1 Property Address:
@"L� �.. �E
2.1 Owner of Record:
Name rint Current Mailing Address: Z�, Z—
L Telephone
ignature
2.2 Auth9bzed Agent:
I j t T f Y-�G- ti�• /G'�
Name(Print) Current Mailing Address:
Signature Telephone
HOW ,k,rV. 5 �
Item Estimated Cost(Dollars)to be �� a� .t.�,.
completed by ermitapplicant �� .` , °, . '` ..ra.r: �>.
�,.. ,
z �_..
1. Building 4 �` r
;tl .- �
� u
_ _
2. Electrical �; �.. �
3. Plumbing .
4. Mechanical (HVAC) a, tiff kA
5. Fire Protectionu�
6. Total =(1 +2 +3+4+ 5) ��
% €
>, —� use Ck^4 t h ��'V ���+•��� „�^rm^�' 3 �� ��n s ��"`
z`: az9z�it .. "�
,�,`tgnature � � � �� � fi ����
File#BP-2015-0056
APPLICANT/CONTACT PERSON ISELIN WOODWORKING
ADDRESSIPHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 1174 FLORENCE RD
MAP 44 PARCEL 113 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid a'7 3X 55
Buildinf Permit Filled out
Fee Paid
Typeof Construction:_REPLACE TILE AND PLUMBING FIXTUIRES
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
INFO ATION 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
emolit* n Delay
I 27�/�
Sig re of Building 6fficilT 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.
1174 FLORENCE RD BP-2015-0056
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44- 113 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 BUILDING PERMIT
Permit# BP-2015-0056
Project# JS-2015-000098
Est. Cost: $9300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ISELIN WOODWORKING 039073
Lot Size(sa. ft.): 93305.52 Owner: FORTIER JOHN F JR&MICHELLE L
Zoning-: Applicant. ISELIN WOODWORKING
AT. 1174 FLORENCE RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224
NORTHAMPTON MAO 1060 ISSUED ON:711512014 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATH
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 7/15/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner