03-027 (4)R `e Crzt�) of �'ior (jalliptoil
� ,. E �iasaatfln�r(la
DEPARTMENT OP BUILOP\1C INSPPCTIONS
212 Main Street ' Municipal Building
Northampton, Ma6s. 010GO
WOIZICEWS COMTENsATTON MSURA.NCF AFMAVIT
(l i cxusxJperrni ttcc )
l,.q'th a principal place of business/residence at'.
-76 fev• Ca..k.r P--(.
(str�.i/ci ty(nalcrzj p )
do hereby cerdi ,, under the pains acid penalties of per3ury, .hat
(pi 10nc-')
Shy -17
(✓jI un an employer providing the followine lvorkcr's coinocns-°L30s" cove:; gc Cor m)
etuptovccs worUng on t1115 )ob
08
(Lflsurzc Corr,: v) (Pciic: Nuab^_r) F: :-p F,4DDau�z)
( ) I am a sole proor,etor, general contractor or homeow-Der (circle one) a-nd have hired
the contractors listed below who have the'MoltiwQ worker's co0:)ens2hon policies:
(Name oI Co..^.t aero )
(Name of CowTacior)
(In�ranc:. Cornpa��yri'cUc,NumLY;)
G1 ,francComoaa�vPolicti \t ncrr)
(Name of Coan-actor) GR uranc Coznpan)•lPoU-cy Numbu)
(Name of Contractor) (Insurance CompZ-oy/P(3ticy Numbes)
(ta--h aMd "-Oe�1 r'xC if nc .: to �'Ci mfocra.,_noc perc� to .1J
( ) I am a sole proprietor and bave no one working for nte.
() I am a home owner pefforTning all the work myself
rl-v: t;,u:o Bate)
(-Expa lion Date)
(Expirtioo Datc)
(Exp tFa6oa Datc)
NOTE: plc be wbo cmplay pc -ions to u-, m-� cG 'rte c rep jr uori: oc . d-• ;^Z of
oa the pvittds
ON mote th_n t� tmi'o in ubich ttx bor.»o-'30rc do or zppvllc ti.r�
lb.__ ax Ec».11y occi:d.. cxi to be
-zployr-t undo the ..uicfs o iioo Act (GLI 52-� 1(5)), cpplicat-ion try a homooava fw : bczzr-'v a P -Mn rr- y e idenoc the
IcgA ctxt- of e c gloyoc under dw Woc4,ola Cooapoos jl on filer_
I vo,&crrtxnd dad a ooyy of thu crxt-o of m.y bo for- —dn d to Lb- Dcputmcnl of Al d-- 0fb- of I,r— for tiv
oovv�&s va-i[Ciioa aid t1 --i f_ilL=,c to ceauc cov,: , under so z on 25A of I.fal. 157 an Iczd to the u^va bOu of crue=l pcnewl
oomuziag of a fiat of up to S 1,300.00a a im(nisoomGii OCUP to ooc ye Lod a ail paulvcm o 0 tx foof a Stop Work Order and e
Ctrs of S too.00 . day t �
For d p..-tnj ur mly---'--- -----
Pcnnil NumtXS
Lot
Signatlirc of l-1=1scc/PcrmiUcc �2
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable ❑
_c
���tt" S P
Name of License Holder:---- 1
rM
(�� `1 �-
License Number
JL f e ry '�. '�
/�'.
l� - c)
Address
Expiration Date
Signage _1 Telephone
9 Reoistered Home Improvement Contractor:
Not Applicable ❑
Company Name
Registration Number
V t-/
Address
Expiration 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 buildina Dermit.
Signed Affidavit Attached Yes....... 0- No...... ❑ 1
11. Holme Owner Exemptions
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 5- DESCRIPTION OF PROPOSED WORK (check all aaalicable)
New House M
Addition ED
Replacement Windows Alteration(s) Roofing Q
Or Doors C]
Accessory Bldg. ❑
Demolition ❑
New Signs [0] Decks [M Siding [p] Other [[3]
Brief Description of Proposed
Ve,--� ' ('D lJ
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes `� No
Attached Narrative Renovating unfinished basement _� Yes No
Plans Attached Roll - Sheet
6a.1f New: house ,snd or addition to existing housing.+c6mplete 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
as Owner of the subject
property
C L fl-` `-1
hereby authorize
to act on my behalf, in all matters r lative to work authorized by this building permit application.
nature of Owner Date
now
s f ^—
, as Owner/Authorized
I— • -<-'
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 thns and pengbes of perjury.
47'
Print Name /
)C7
—/
Signature of Own/tr/A-gent Date
Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
NLS e "fj U � x 1 -j -r) rd This column to be filled in by
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 Parkine SDaceS
Fill:
&
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 0
IF YES: enter Book Page, and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW 0 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 er
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
212 Main Street
`J - ' "' " Room 100
NOrthampton, MA 01060
- 7pftone.41X587-1240 Fax 413-587-1272
APPLICATION 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
�/f�
Y'5 ,r' C 1E1 / "i-eG `�'^� jZ`'�.
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
f
Name (Print)
Current Mailing Address: 2-f-
Telephone
Signature
2.2 Authorized Agent:
40 'p %ser.
6 sl -/V. « (-e, 12 -
Name (Print)
Current Mailing Address:
1
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by permit applicant
1. Building
(a) Building Permit Fee
2. Electrical(b)
�i j -o®
Estimated Total Cost of
Construction from 6
3. Plumbing
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
Z-
6. Total= (1 +2+3+4 + 5)
.7 c7
Check Number
This Section For Official Use Only
Date'
Building Permit Number:
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
File # BP -2008-0121
APPLICANT/CONTACT PERSON Oliver Iselin
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413) 584-1224
PROPERTY LOCATION 595 COLES MEADOW RD
MAP 03 PARCEL 027 001 ZONE RR/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
ilding Permit Filled out
F
Typeof Construction: CONSTRUCT NEW BATHROOM/KITCHEN & FINISH BASEMENT WALLS
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
INFORMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND/OR
Major Project: Site Plan AND/OR
ZONING BOARD PERMIT REQUIRED UNDER:
Finding Special Permit
Special Permit With Site Plan
Special Permit With Site Plan
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Water Availability Sewer Availability
Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
08 ,
/ 7
Signature of Building dficial 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.
595 C010 -BP -2008-0121
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP -2008-0121
Project # JS -2007-001602
Est. Cost: $46600.00
Fee: $185.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sq ft.)_ Owner: DENHART BRETT C & DEBORAH G
Zoning: RR/WSP Applicant: Oliver Iselin
AT. 595 COLES MEADOW RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:8/6/2007 0:00:00
TO PERFORM THE FOLLOWING WORK. -CONSTRUCT NEW BATHROOM/KITCHEN &
FINISH BASEMENT WALLS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
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 8/6/2007 0:00:00 $185.001797
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Building Commissioner - Anthony Patillo