28-013 (4) l '
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SECTION 8-CONSTRUCTION SERVICES'
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: '7�Q� "� O ]S 0 73
License Number
Address Expiration Date
Signature Telephone
9 xRi" r"edkH me:lm r yeF7rznt"Contr`aafdr t ff� #,.. , A Not Applicable ❑
Pp ". .,«K ,
X28
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c, 152, §25CM), ;
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....... ❑ No...... ❑
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t><<ari
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 force 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
-ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [✓, Siding[ ] Other[ ]
Brief Description of Proposed Work: /ZEr t AC J( EJ<<17-)•'►6 J)604- /P4 1-4or4-p-AJ
Alteration of existing bedroom Yes X— No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet H*�
6'a;t fi[" ►=ti' a nd., atld"t an o-ex'stin ho"s�:� com°"le. t fO ` w"
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 h•_ating? 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
SECTION 7a DWNER AUTHORIZATION-TO BE COMPLETED- WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize .1��'E L; J to act on
my behalf, in all matters relative to work authorized by this building permit application.
nature f^wne 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 pains Pod penalties of perjury.
4-T S 1 cL-1 f L).mil
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
Q C T &*—j 70 This column to be filled in by
� f r G Building Department
Lot Size U,
Frontage / �✓ ,
Setbacks Front l00
r
Side L: R: L: /JD t
Rear 16
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:
I' 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
212 Main Street
Room 100
7
Northampton, MA 01060 $fm<, '
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ASR 2 ? �v�4
SECTION 1-'SITE INFORMATION
1.1 Property Address: � '`
This s+rction tab omp of d office ; r
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SECTION 2- PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print) Current Mailing Address:
duhjL IT b S"gr
Telephone
Dign ure
2.2 Authorized Agent:
71 ,d 1 k .L f t- w 'J �b 64 v)c& C 4-"5*14-
Name(Print) L /� Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION'COS'LS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1_ Building 1.41 c7�o (a) Building Permit Fee ',
2. Electrical _� (b).Estimated Totaf Cosfof .
Construction'froiYi 6
3. Plumbing Du:ilding ?ermitee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(I +2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: e q Date Issui.
Signature:
Building Commissioner/Inspector of Buildings Date "�
File#BP-2004-1032
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
Fee Paid
Typeof Construction: REPLACE EXISTING DECK
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
INF9RMATION PRESENTED:
pol 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 Co 'ssion
r 2 oa
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.
256 SYLVESTER RD BP-2004-1032
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:28-013 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-2004-1032
Proiect# JS-2004-1553
Est. Cost: $14000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(sg.ft.): 390733.20 Owner: LOSERT KIRSTIN
Zoning: RR Applicant: Oliver Iselin
AT. 256 SYLVESTER RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:4129104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING DECK
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• Receipt No: Date Paid: Check No: Amount:
Building 4/29/04 0:00:00 1443 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
tit MAW�T
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`k City of Northampton
" BUILDING INSPECTION LABEL
°LXSPPR VEE)
t/ 5 ainspector
Date
i
256 SYLVESTER RD BP-2004-1032
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28-013 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-2004-1032
Project# JS-2004-1553
Est.Cost: $14000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Oliver Iselin 039073
Lot Size(s�1c.ft.): 390733.20 Owner: LOSERT KIRSTIN
Zoning:RR Applicant: Oliver Iselin
AT: 256 SYLVESTER RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:4129104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING DECK
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:�JeZ- S c9h
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: O
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS r"
Certificate of Occu anc Sip-nature:
Xi
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 4/29/04 0:00:00 1443 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Comnussioner-Anthony Patillo