29-494 (3) 4.StiAM p�O
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t' DEPARTMENT OF BUILDIl`G INSPECTIONS
2�2 Main Street ' unicipal Building '
Northampton,1W ass. 01060
WORKER'S COMPENSATION INS CE AMZMAVIT
(licensefJpe�mittee)
with a principal place of business/residence at:
(street/ci ty/staie/zi p)
do hereby certify, under the pains and penalties of penury, chat:
( ) I ,-in an employer providing the following worker's compensation coverage for my
employees working on this job:
(lns-L=ce Company) (Policy Number) — (Expiration Date)
O 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 Company/Policy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Compar y/PoL cy Nurnlx-r) (Expiration Daze)
(Name of Contractor) (Insurance Coropam/Policy Numb-_T) (Expiration Date)
(attach amitiooil sb.c if nccc xry to nc}ude information pertaining to all ox±me-orn)
i
( ) I un a sole proprietor and have no one working for me-
! l am a home owner performing all the work myself.
NOTE:plcasc be nµ-arc drat)Abilc homrAwtxta who crnploy paTo:n to or repairµuric on a dNktirng of
not mc"than Ur c units in�siiic i the hotmo«vcr resides or oa ti,-g ou x zppurtca r1 the ctn etc oo(g�y cocsidatd to be
rntployczs under 4>G u a ku s 0_4t;�ticn Act(GL152,"1(5)),application by n hot 00%na for a liaszse oe permit may evidcmoe the
legal ctatva of en employer under rho Wocicor'a Compo nAL Act
I understand that a copy of this ctatcmcoi may bo forwarded to tho Dcpert.a of inausiriel A«.&--,ty Offioa of Inauance for the
covmgc vaificslioc and that failure to acatro covcrago undtr scctioa 25A of MGL 152 can Iced to the imposition of criminal pcnaltics
oom.isiuig of a fine of up to S 1,500.00 and/or imprisoameat of up to one year and civil pcml6ci in the form of a stop W oric Ord--and a
firm of 5100.00 a day against me
Foe dcprrtn�uao oaly
Permit Number
Map',t Lot tt
t tore of Lid ttee �� -
SECTION,8--.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� ee�sred Horrielmprove'merttContract„oar - a "'� Not Applicable ❑s .N
Company Name Registration Number
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 affid�
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
�1 �-Y m9 � �.inie -2 `II, ri.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(
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 ai Local Zo ing Laws State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION53DESCRIPTIONOF PROPOSE 0' K Lheck all applicable)'
E
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [7 Other [ ]
Brief Description of Proposed Work:_ Pb(, �rN 5 s� rl l N29
Alteration of existing bedroom Yes No Adding new bedroom Yes �� No
Attached Narrative ❑ Renovating unfinished basement Yes G-�N o
Plans Attached Roll ❑- Sheet❑
6a tf Nervy'fiouSe ncl or acidit"ian to ezistin`g K6using;=c6gig1et"h"e..fol°IoWJnk.:
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?
h. Type of construction
L Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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 prop(
hereby authorize to a
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, , as Owner/Authorized Agent
hereby declare that the statements and in`ormation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print N m
Sign urDate
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
f Existing Proposed Required by Zoning
+ 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 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:
City of Northampton
Building Department
212 Main Street Se ' Steep ;
Room 100 v
ampton, MA 01060 o et� tre.;
phone 4 `' 7.1240 Fax 413-587-1272 Plod/Sete
Other Specify
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 bye com pleted4by offrce
4 f R
Map Lots tJn�t
Zone Overlay D�stct � �
Elm St.'District CB District"
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mai!i dr sscl:3 —
_ Telephone
Sign ure _
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone ,t
SECTION 3 -..ESTIMATED CONSTRUCTION COSTS 1 0 0 U
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee'
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section for Official Use Only._
Building Permit Number: Date Issued:-
Signature:
Building Commissioner/Inspector of Buildings Date
1
415 RYAN RD BP-2002-0395
a
COMMONWEALTH OF MASSACHUSETTS
MV.--BI-wk:20-494 ; - CITY OF NOR.TILAMPTON
Lot:-001
Permit: Building
Cate_gory:vinyl sidine BUILDINCoPERMIT
"memo
Permit # BP-2002.-0395
Project# J5-2002-0603
Est.Cost:-,2100.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO.
Cont.Cuts: Contractor. License;
Use Grouu,
- Lot Ste(,,g4.it): 20168.28 Owner: RYAN KEVIN J&LORRA NE-A
Zoninn:URAaSP Angl&0t• RYAN KEVIN J §1 LORRAINE A
AT.- 415 RYAN RD
Aggkent Address: Phone: Insurance
415 RYM RD X413) 584-0322 O
FLORENCEMA01062 ISSUED QN IWI 0:00:00
TO PERFORM THE FOLL0WING WORK:INSTALL SIDING
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 Finale
Final: Final:
Rough Frame:
Gas: Fire Deuartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:67/C
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occugancy si nature:
Fee Ty ne• Receipt No: Date Paid• Check No: Amount:
Building 10/11/010:00:00 2476 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo