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DEPARTMENT OP BUILDING INSPeCTIot'S �
212 Alain Strect ` Municipal Building
Northampton, Mass. 010GO
NVOMa'R'S COMTENSATION INSUR,"CE AT, , AVj-j'
(li ccuscclpern�i ttc�}
With a principal place of busioess/residencc at:
�� ��✓, `� ✓ (phone:')_ V/ 7 jW�Y l ZZ-y
do hereby certify, under the pains and penalties of perjury, .hat
(VrI am an employer providing tlic following workers coinncnM�Jor; cover2ge for my
employees working on Lutis job.
Wl . )FfC b oe - t/yvo•Tu- Z 0ll-A 7 ► � � b
(PoUc-, Nunabcr) (r;piraCion Datc)
am a sole proprietor, general contractor or homeo��,ner (ci c e one) and have hired
the contractors listed below who have the following workers comoeljsnon policies:
(11aII]C Oi CO.^.0 1Ci0r) (iliR 3111 QITlD3 i)'i �Gl1C{ atysp �. �_X;)It'dtipr? D'11C)
- (Name of Contractor) _— (lnswzncc Comoaay�Po!ic� \uzncrr) �Z>u Lion Date)
(Name of Contractor) (Ilsura.nc; Compa yfPoUcy Nusbzr) (E\pirdou Date)
(Na-me of Contractor) ansurmac Compwy/Pobcy Numbs) (Expiratio❑ Date)
(eaa.dt 1ddi�ocl!s' ,Ci unccti-.,y to mc?u(:infataa:•ioc paviaius to aU
( ) I am r sole proprietor and have no one working for me.
( ) I am,a home owner perforating aU the work myself
N07 E:plc,:be nw^ut tb .v.•t )c 6cmco ivm ubo craplay Acton w do xAj=Lcj. _�::cJvo cr rcpzir.ork on.dx%,l:&or
Do(moce tb:n tso_t-,Irj in the bom.0 0,"=uda o oa Lbc U-ok�Z,,Pu nr tbcti &'c o% y OLCr.d.--d to be
utploye-�utx',c ibc wui(rt1 slim Aci(GL!12,s r(S)),:pPlicvwao try n homooava fet c Lesr.a permit rr:y c.idcnae the
Ic�1 rv�u of nn e=ployor uo&o dw Work-ce.Coolpocaay�AC(-
f uodcrz,ud t'h�a Dopy of this rn,t<.mras m.y bo(orwtir¢Sed to t,w p���,�of loduttie7 Modal Offioa of 4rxut.000 foe thv
coverage vaif ciioc a.'td oi--i UL—c W sea n cov rye ta�dcr soctioa 2 SA of I.toL 1 S2 an tad tn'tbc a xutioa of cximia�!Qcu>ltio
0001&,ins Of a ED,-Of Up to S 1-500.00 and/or Of up to OTX yC:f t xi ci 11)P=W rJa jr,t.SG form or a Stop Work Ordr_r n.od.a
fim of S I(X7.00 i day cpa=tDc
/ For dcp.rtnr_,:.i7 u,c only —•---------
L 1 / Permit Nuu7ber
l.ot
SiI nature of Lico>scr/Pcrtnitt, 3 e
City of Northampton 212 Main Street, Northampton, MA 01 060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by:
The debris will be received by: SIP
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
I Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �I ` c S Q O 312
License Number
Address Expiration Date
Signature Telephone
J-eq- i2L
Not Applicable ❑
1 N 73-1 F
Company Name Registration Number
- y - / 6
Address Expiration Date
Telephone
Mk R20P
�Y
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....... 1i 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 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
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
Xj-U 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:
7 7
New House 13 Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: 7tp I Q�� �J 6 N D"`� /J�ti�t o..�, /�G flu�r�2 60k 47K4-.,'t4
Alteration of existing bedroom Yes '� No Adding new bedroom Yes �No
Attached Narrative❑ Renovating unfinished basement Yes -'N0,
Plans Attached Roll ❑ - Sheet❑
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
I, Q` �` �►� ���
as Owner of the subject property
hereby authorize E-I 0 to 4 fi�� 1 1 n to act on
my behalf, i r, II matters relative to work authorized by this building permit appli ation.�� A /Ad f/
Signature of Owner D e
as Owne thorized 2 e
hereby declare that the statements and information on the foregoing application are true and accurate, to the my
knowledge and belief.
Signed under e p ins and pey hies of perjury.
Print Name
e
Signature of Owner/Agent Date
j J
A ty of Northampton
ilding Department
212 Main Street
DEPT_OF 6uADl'JG INORTHAMPTON. Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
oft 4
INN
1,1 PrODerty 4ddress:
36 �? ��•rte� �Z��L�
2.1 Owner of Record:
pis feS s� -�-
Name(Print Current Mailing Address:
Telephone
oignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
Item Estimated Cost(Dollars)to be
com leted by ermit applicant
1. Building
�'. .,,, ��;»u,.zt.n ..,� .4Fn�S5'i'�m�i�.ca..6b�,PRa:'u.<....u. �.M`€'•�., .,r sf� �..:..a Z�*o-..r»�.'�t_.,,.,_
2. Electrical
3. Plumbing
4. Mechanical (HVAC) «
Pv
5. Fire Protection :
6 Total (1 +2+3+4+ 5)
v
r
w
,u7 AT
36 POMEROY TER BP-2016-0959
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-233 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0959
Project# JS-2016-001627
Est. Cost: $4760.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sa. ft.): 23348.16 Owner: CHRISTAKOS PETER G&DEBORAH S
Zoning: URC(58 /� SC(42)/ Applicant: OLIVER ISELIN
AT. 36 POMEROY TER
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:21112016 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATH & REPLACE WINDOW
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 2/1/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner