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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(liCense(Jpermitzee)
with a principal place of business/residence at:
(phone#)
(streetici ty/statrla p)
do hereby certify, under the pains and penalties of pemiry, that:
%
/_n am an employer providing the following worker's compensation coverage for my
employees working on this job:
AW 7&9
Aw2zw,�,s.
�1 (Insurance Company) Volicy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Cornpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(a(1ach additioml sbed if neoeasry to include infarmaIIoa pertaining to all coatrncLosa)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wbilo homansven who employ persons to do maic�construction or repair work on a dymlling of
not mace than throe units is wEch the homoow=resides or on the grounds appurtenant thereto are not gax mity considered to be
employs o under the vmrkes anion Act(GL152.ss 1(5)),application by a homeowner for a U-se or permit may-id—the
legal slaw of an employer under the Workvrdt Compomatioa Art
I undetsiaad that a oopy of this ttatcmeat any be forwarded to tbo Dcpw mm2 of Industrial Accidm&OHioc of InvIranoa for the
coverage verifiartioa and that failure to secure mvarago under section 25A of Ml3L 152 can lead to tbo imposition of aiminal Pena -
ooasisemg of a fine of up to S1,500.00 and/or imprison of up to one year and civil pcoalt cs in the form of a stop Work Order and a
firm of 5100.00 a day against mw
For dcputmm>bl use mtY
Permit Number
"j �' "✓, �'—� �� Map# Lot#
Signahtre of Licensee/Permittee e
�p.
Mar OG 00 10: 03a
8.1 Licensed gonstiruction 5gDerviscir: Not Applicable 0
License Number
Add�ress , Z- 7- ExpirationDate
Signature 'Telephcre
Z�ciiiii�—any—Name Regisi,aUon Number
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 162, §260(s))
Workers Compensatior, Insurarce aff cliv,t -m.-st he co-n-)Ieted arici subiritTed with J is appiicatlon. Faftre tc provide this afficavit
Signed Affidavit Attached Yes ...... 9--' N o 0
The current oxnmpdop for'hoo,o°n:m''was ex:eu&dminclude one(I or mvo(2)families
and to allow such borricowner,cencyage an individual for hire nbdoe.;not possess ulicense,providtd that the owner acts
as supervisor.CNIR 780, Si--th Edition Section
Definition of Homeowner:Person(o)who own a parcel of land on A-"iich k'she resides or intends to resicle,on which there
is,or is----dtn be,a one v,livv family dvr0in8'uua::hcdordovac6*dstruuturcaouoc,xvrN.to,uchuxndri(ilvrfarm
structures.A person who constructs more titan one borne in a tivo-year period shall not be considered a homeowner.
Such"hoo`oowuor'shall xuuin;t tu/uoSmmmg Official,omu form uccepmmum die Building uufioi
Lesponsible r all Agili woEh performed under the building permit.
acting/� d the job site*i)ihe required from time tn time,during and upon
completion of the work for which this permit missued.
Also 6e advised that with reference m Chapter |52(Wo6ro'Couipeuuatioo) and Chapter|B(Li^h^Utyof Employers/o
Employees for i�urie not osuUi/qginDcm6)o[�vK1x,`ao"useusGoueo\Laws Aou�mod, 5urmxsun(s)
you hire t^y°,«um`wo,k for)oo under this permit.
The undersigned;'homecwfier"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws ard State of Massachusetts General Laws Annotated.
Homeowner Signature___ _
Mar 06 00 10: 02a p• 4
SECTION 5•DESCRIPTION OF PROPOSEQ WDRK(Check a a Ilcab
New House ❑ Addition ❑ Replacement Windows Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: P ,*c-16- &>-I1 rn aC 't °rt try e� -fl,,Je,Tl
Alteration of existing bedroom Yes �fv'o Acding new bedroom Yes Z�NO
Attached Narrative❑ Rerovatirg unfinished basement __Yes
Plans Attached Roll D• Sheet
a. Use of building:One Family Twc Fami y Other
b. Number of rooms in each family unit: Number of ?athrooms
c. Is f)ere 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. Mesche--x Energy Compliance form attached?
h. Type of construction
I
i. Is construction within 100 ft. of watiands? 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 iuilding and Zoning regu!atiors% Yes No.
1. Septic Tank City Sewer Pr�a`.e well City water Sapply
SECTION 7a-OWNED AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT dR dONTRAGTQR APPtsIES t6lR BUILDING PERMIT
Aft 1-v , as Owner of the sabject p,operty
r -
hereby authorize _ r- J G to act on
my behalf, in all matters relative to work authorized by this bui ding permit application-
Signature of Cvmer 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 pans and penalties of cerjvy.
°r!nt Na
Signature of Owner/Agent date
Mar . 06 00 10: 01a p. 3
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Frorx�sed Required by Zoning
This.olumn to be filled in by
I /v! Building Department
Lot Size
Frontage
Setbacks
Side L:_ R: L: R:__
s
Rear
1
Building Heigh
Bldg. Square Footage I o
Open Space Footage o
(Ut area minus bldg&p.'d
puking) t
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 pern-it recordeC at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page___ and/or. Document#
B. Does the site contain a Brock, body of avatar or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been o, need to be obtained from the Cor,servatior Commission?
Needs to be obtained Obtained . Date Issued:
C. Do any signs exist on the property? YES NO f' _
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;
.t
+ Mar 06 00 10: 00a p• 2
�{'K
icy of Northampton1 �'
iidi-ig Department �� � -•
3 f� 12 Bain Street 114
Roo 100 a; IR
dot air tors MA 01062
'tE orewom 7.1240 Fax 413.587- 272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I-SITE INFORMATION
j 1.1 Pro�rty Address: 'k'Elt Gffdfitt ff�b"��ompl tetl,by offr
r.!
z
� Zdrie �t'1ay Drstra�t '� �M�
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record•
Name(Frint) Current Mailing Address:
Telephone
Signature
2.2 AuthorizedAzent;
r ✓k-rc
Narne ), _ Current Mailing Address,
Signature -e'ephone �
- I
SEC TI N 3• ESTIMAIW CQNSTRUCTION CASTS
Item Estimated Cost(Do'lars)to be 'Official Use Only
com feted bZ permit applicant
1. Building , (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Constructi n from(6)
a. Plumbing Building Perm i Fee
4. Mechanical('NVAC)
5. Fire Protection `
6. Total =(1 +2+3 +4 +5)_L Z u'"mod Check Number p�
- --- — —
ThisSectlon.For Official Usk Only
Bthld,iiig Permit.Number:. Date Issued:
5ignatur�: _ _
Building Commissl,�ner/nspertor of 130iding5 pate
Y
File#BP-2001-0607
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center (413)584-1224
PROPERTY LOCATION 50 UNION ST
MAP 32A PARCEL 058 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: INSTALL NEW WINDOWS&REPLACE KITCHEN CABINETS
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 LLOWING 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 Comm1ssi9R7 Permit from CB Architecture Committee
Signature of Building Offi ' 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.
I
,�14�10
k
50 UNION ST-UNIT#5 BP-2001-0607
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32A-058 CITY OF NORTHAMPTON
Lot:-005
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2001-0607
Project# JS-2001-1086
Est. Cost:$22000.00
Fee:$110.00 PERMISSION IS HEREB Y GRANTED TO.
Const.Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq.ft.) Owner: LAFLEUR A.J.
Zoning:URC Applicant: Oliver Iselin
AT: 50 UNION ST - UNIT #5
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON.•1 181010.00.00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW WINDOWS & REPLACE
KITCHEN CABINETS
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: r 3// ` Rough:Z`�(6) ( House# Foundation:
Final: Oj Final:
Law�• ac 4/t40l e..-- Rough Frame: Olef —O
yo 7/c
l
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:®�
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy si nature:
Fee Tyne: Receipt No: Date Paid: Check No: Amount:
Building 1/8/010:00:00 1022 $110.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo