34-003 (16) O�11VJ f pTO
A (rTt-L) Of �\To fljallipfoil
t� ��R36 AC{I I1L(ll6
DEPARTMENT OP BUILDR\IG WSPeCT10T.'S 1 _
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S CO?V[PENSA'nON LNSURANCE AFFM VIT
t
�r
(li ccusu_Jpern»ttc�)
v.9tb a pi-Mcipal place of busluesslresidence at
1
I?j _ s hone ) `�I-2 J�'y 9 2,? `
(SuccuCc ty/stalerp)
do hereby certify;, under tic pains and penalties oft pcf3ury, ?hal
( ) I am an employer providing t71e following WOFL-cr's coinoclns:::-lon cove:2gc for illy
eluployces worming on tills job
—
(In=---= Coo=v) (P0 Nt ter) Date)
( ) I am a sole proprietor, general contractor or homeowner (ci ce one) grid have hired
the contractors listed below who have the follo%vinQ worker's corn-3ensaaon policies:
(Name o; Co.nlrncw0 ) )G6C
(Flame of Conrracior) -- (IISa12nCC CoEoDanwPo!ic-t \urlcrr) (L�pit:lio❑ Date)
(Name of Contractor) (Insw-afic Compi-ay PoUq Numbu) (E\piruoo Date)
(Name of Contactor) (Insurance Company[POLCy Numbs) (L- �I-M Date)
(e¢zcfi �OcaJ c' Cl Uuc-�.ry to a uci-wforcu�oo perta:n:nb to all oo�r._c.o-�)
O I am a sole propnetor and have no one wor4-.ng for me.
( ) I am a home owner perfonuma all the work myself.
NOTE.:pf� be ewa :O e utrJc txar_rn{v-n wIco mplay pz- r to e � ,ccs-c c r ur.•or o�.d.. tL,i of
ON tnocc th-n LTA -t=i'j in.-a I*Ch the hatn!Xl«'DCi rtydo a oo the V0,..tnd3 the 1�o-x C:-Ily occr:d--I:il w be
c;;tpioyc3 tto thek&1 cc!�lioa Act(GLI --pplic nc-o by n hcscoa�r fa c L u pvm y d nx tr
)cS.j L--t.of ca c=Ploycr Under dao Wocicoe,Coa pomRiion AC—
I uodcn nd[lrt a copy of(his aatcm may bo focv nrdod to ho D,,—�wm of Indus i J Am dam&OLL oo of In r.o0o fx kae
covcriSc vcnf cnlioo and tthl L dtzrc to cccauc covcnTc under-,c oa 2 S A of MOL 157 m Ic d w the i�—of criminsl pcatlficn
ooani of R fir-of trp LOS 1 500.00-10or emTai3�oCup to one yvr tad a�iJ pc).Pio LO tx form or R stop Wrn'k Order end R
Cim o(S 100.00 1 day Rpiwa m
u-J
PCTIIl)t Nt1JIlbC1 ------
// Lot ---
Signaturc of Liccli-sccAIcrn6Ltu-
$�rill M i lQN'Si7' S
1 Licensed Construction Supervisor: r Not Applicable ❑
Name of License Holder
�lI tJ-t T ��S� l�- 1G' •�
License Number
b J P.-✓) c� C�� f�' C 1 f S` - / 7-
Address Expiration Date
Sigma ure Telephone
. � , , Not Applicable ❑
a� U.uFl�.,, .
z�'
Company Name Registration Number
P l Vl t 6
Address Expiration Date
Telephone
SECTIOtI 111f1RS' V[PIN�s/411'1NS�RANCL pF11DA1T(ill�, 52,§25C(+}
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...... ❑
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 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
"ECT14N -.ClE6; !P'Tl >I�a :P Pt?SEl7►1NORK :ch �k 11� i ple
New House ❑ Addition ❑ Replacement endows Alteration(s) ❑ Roofing ❑
Or Doors
i Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other[ ]
/ Q C c� (CSC ►`1 E�"� t� J „� €.
Brief Description of Proposed Work: ! {
I
' Alteration of existing bedroom Yes ✓No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes ✓No,
I Flans Attached Roll 13 - Sheet❑
► i
= a. Use of building: One Family Two Family Other
9{ b. Number of rooms in each family unit: Number of Bathrooms 1
c. Is there a garage attached? j
d. Proposed Square footage of new construction. Dimensions
,
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
i g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
I
E t. Is construction within 100 ft. of wetlands? Yes No. is construction within 100 yr. floodplain _Yes—No 1
p
Depth of basement or cellar floor below finished grade
i
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SE
G l<xON
OWt1Eft5 A,rE Q Ctt+1J11' ►R�15fll�" fia plEtMiF7
' ti+ J ► as Owner of the subject property
her, authorize �' ✓e S� `M to act on
m e aIf, in al afters relative to work authorized by this building permit application.
Signature of Owner 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.
3
Signed under the pains and penalties of perjury.
s
� Print me �
ZI
l 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
This column to be filled in by
C C ( Lt W1 �) k t✓^ 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 t site contain a brook, body of water or wetlands? NO DON'T KNOW —
YES t
IF YES, has a permit been or need to be obtained from the Conservation Commission? d
Needs to be obtained Obtained Date Issued: r l
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:
T
RECEIVE
ty of Northamptonx
I B ilding Department
DES of aUI DING NSPECnCNS 212 Main Street '
NORTHAMPTON MA 01060
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
SECTI4N1 SI�'E tNORM�'{�ION
1.1 Property Address:
All
(tit
$ ?ryt P Y
r v
F SECTION'2-:PI'tOPERTY 011f !^tSM1PfA lT41ORiZ b A MT
2.1 Owner of Record:
e rint) Current Mailing Address: 7 �7Y l 3S9 y
Telephone
ature f
2.2 Authorized Agent:
C1,0 -,- r set fit,
I Name(Prin Current Mailing Address: J
1-Z-
Signatu Telephone _r i
sECTiN 3 " iES7'tA+lATf? olf4sTkUrrTilifJ COS75
Item Estimated Cost(Dollars)to be n !
1
completed by ermit applicant
1. Building l �.�� (,a) t1g:Permtt I~ N
2. Electrical �-. ( ) eated Touto af,
10 .'S' ior►frc ,3
3. Plumbing - B �tkirr'mit �
4. Mechanical (HVAC)
5. Fire Protection `.w.. =
6. Total =(1 +2 + 3 +4+ 5)
` Chiaber
n
'h15 + t�nair,Uftc�a �dinl
i
Building.Ferrnit Number. °bate issued"
Signature:
8uaidtng Comrt�issionerlinspectar of°Buildings Date
267 TURKEY HILL RD BP-2016-0556
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 34-003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2016-0556
Project# JS-2016-000913
Est. Cost: $15000.00
Fee: $80.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: OLIVER ISELIN 039073
Lot Size(sq. ft.): 178247.52 Owner: PINNEY JAMES
zonine: Applicant: PINNEY JAMES
AT. 267 TURKEY HILL RD
Applicant Address: Phone: Insurance:
767 TURKEY HILL RD (413) 341-3594 Workers
Compensation
FLORENCEMA01062 ISSUED ON.1012112015 0:00:00
TO PERFORM THE FOLLOWING WORK.•STRIP & SHINGLE ROOF & INSTALL
REPLACEMENT WINDOWS
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 10/21/2015 0:00:00 $80.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner