28-013 (3) i
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Commonwealth of Massachusetts -
City/Town of
Certificate of Compliance r
Form 3 Jul 1
M
DEP has provided this form for use by local Boards ofHeel�h„Other forms inky be used, but the
information must be substantially the same as that provided here. Before using-thls form, check with
the local Board of Health to determine the form they-use.
This is to Certify that the following work on an On-Site Sewage Disposal System
Important:
When filling out ❑ Co struction of a new system
forms on the ❑ pair or replacement of an existing system
computer,use Repair or replacement of an existing system componentggrlee�
only the tab key
to move your
cursor-do not Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
use the return r V ao / bIy �c�
key. (� L%J y
DSCP Number y� DSCP ate
V 'J /14 5 / /IJ tq S'e�
Facility,¢weer_
Street Address of L #
City own State Zip Code
Designer Information:
Name Name of Company
Signature Date
Installer Informal'on:
N meQ 1 t ^ D ^� Name of Comp
a
Signature 'yJ\ a( C�J Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
desi �. d or
rov ing h r _ !
SignaturJ Date
t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1
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DEPARTMEiIT OP BUILI)f.0 INSPECTIONS --�
212 Main Street ' Municipal Btiliding
Northampton, Mass. OlOGO
`'VORICsR'S COnVENSATION INSURANCE A MAVIT
(licct5 cclpertnittc�) _- --
\11ritb a principal place of business/residence at:
(� ( ✓. C iZ�- ,2�_ (phone.., Y(J Jr' LY
-- - (sm-r..l/city/statclap) .
do hereby certify, Under the pa_iris and penalties of penury, :hat
( :m an employer providir-Ig the r°oilo\vinc %vorker's c0inoc'1S-at10;: coven_e For 111y
etnplovees tvorkang on u)is job:
OJ3. -�Q Comp n.) (Pclic: ?�urnixr) — FExpirztion, Date)
O I am a sole proprietor, genera] contractor or homeowner (cifcie one) and hive hired
the contractors bsted below wbo h2ve the following :vorkel's caopensaaon policies:
(Nam-, of Co^t:;tcto') (lnsuranoc Coinpan)-iPcUq, (I_xpli.ltiOfl Mite)
(Name of Contrcror) -- (lns-wanc;, Comoa y/PoLiLv i~mina) (-Lxp ,:lion Date)
(Name of Contractor) (Inalrancc Cornpa ly[Pol ey Ntt kj) (Exairdoo Date)
(Name of Contractor) (Insurance Compagy/PoUcy Numbs) (Expiratio❑ Date)
(and ocid rbcC if nc -ry w ax'ud~infort=A-#ioe petta.iaiog to•1t ooa73t o�)
( } I am a sole proprietor and bave no one worldng for me.
( } I am a home owner perfotrning all the work myself.
NOTL plc l,c cw+ rc t4,.,vt-Jo bcm o+vcra Wbo mplay p,=o w repair-ork oa.d.,,,U--g or
oot Wo"1&'x ` .�,j in�tticb ebe bomoo-.+vcr r c�d-,oc oo the p-ouod3 x,purtca:.-ther-.n c.�r nx Ceie--.11y axsd�d to be
=ploycs uodc-the koi ds oa>=p=�1ion Act(GI-152-1(5)),application try n bomco-v fm-bc----a P=° rr; y ccidcaoc tL-
lcpJ M--t-of m c-s.,loyx under d3a WortCOrr CgmpesaaS,ypo Ad
1 uodc YLx d dw a oopy of chi. my b•fot-wnrdod to tbo Dopv%.,w of].&Leii j AcndocL!off-or i,�for the
oovcnge vu-&C=600 Aftd that L•it=t.o scum eovtiTuge tattler ioaiofl 75A of MOO 151 can Iced to the jzposIIiov of crimiast peonities
oocairi;tg of a lane of up to S l,500.00 an&cx az isoomes!of up to om year and civil pmat io io 6c ram of.Stop Work otdCr and a
fun of S 100.00 a Icy cptioa me
- For dc�..rtm.=^i1 v,e only
?���r l�� Pcru>.it Ntunbcs
SipDantrr of 1 �m++�.•,-/D�•-.••. r�� - F�
� r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Num er
Address Expiration f5ate
14Y - , ILL
Signature Telephone
1 .Rec stered Horne Improvement Contractor: Not Applicable ❑
IfK4/"� /-? 7 f Ld
Company Name Registrati n Nu berg
o
Address ExpirafioA 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....... vrl No...... ❑
11. -Home-Owner Egem don
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
c
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[O] Other lm9
Brief Description of Proposed _ O ()
Work: � }�f v c�' )... . A✓ e� cJ h►i..w,n 4 ✓Z+b /'
Alteration of existing bedroom Yes -'-�No Adding new bedroom Yes -'�'No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll -Sheet
6aAf. New house and or additibh 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
1,__ /" l rS P "-f*-K f , as Owner of the subject
property
herebtbehalf,e
to act in all ma ized by this building permit application.
Signa re of Owner Date
4 �� ` 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 he pains and peaplties of perjury.
Print Na
6
Signature of Owner/Agent Date
f ,
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 _/ y• GichK7
Frontage ✓"t?
Setbacks Front
w.
Side L:Tr'0 R: .ep, L
Rear Z`"0
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 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f . r
City of Northamptoninttx � ,
Building Department
n _
2,12 Main Street 8
Room 100
Aorthampt n, MA 01060
phone 413 587-124 Fax 413-587-1272
�5 e, �
APP*A77UN 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
Z S(. S71 v[J�s /2d• Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'tr tz rr,-j LoS�E-�T y Nit/ /�i .j'L tl 2�6 .j'yc.✓�frL�-rc 1W.
Name(7i —�.1 Current Mgji 5-
Telephone l�
Sig t re
2.2 Authorized Agent:
yj/ ,G�.S•E /..l ,� f��c V► C�� K fin.
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0VV (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Z L-rv° Construction from 6
3. Plumbing j Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2008-1079
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584-1224
PROPERTY LOCATION 256 SYLVESTER RD
MAP 28 PARCEL 013 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ",-y i
Fee Paid
Typeof Construction: CONSTRUCT 20 X 40 INGROUND POOL
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 ATION 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 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.
BP-2008-1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
"' r n,"' 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-2008-1079
Project# JS-2008-001593
Est. Cost: $39000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq. ft.): 390733.20 Owner: LOSERT KIRSTIN&MARA SLAWSKY
Zoning: RR Applicant: Oliver Iselin
AT. 256 SYLVESTER RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:61512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 40 INGROUND POOL
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 6/5/2008 0:00:00 $50.001846
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo