35-047 (4) Version 1.7 Commercial Building Permit May 15,2000
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A_RF`MAYTr
(Iicen_Seclpermittee)
with a principal place of businesslresidence at:
(phonef#)
(s-L-cet/city/sta Zip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worlang on this job:
(murancf-- Company) (Policy Number) (Expirat on Daze)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the followiDg worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Nurubcr) (Expimtioa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Fa-piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shca ifnccczvry to iachrde inform .pauining to all oortrad.ors)
( ) I am a sole proprietor and have no one worming for me_
( ) I am a home owner performing all the work myself.
NOTE:please be aware this while homeowners who employ pens=to do ma at� oa or-pair Mork oo a dwelling of
not more than throo units in which the homoowna resides a on the grounds appurtcnsnt thereto are no(grna'ally 000sidacd to be
eztploy)=under the work companion Act(GL152$s 1(5)�application by a homeownis for a license oc permit may evidcna tho
Icg4 etahts of an amployor under the Woficods C.ompomdioa Act
I understand thst a copy of this etatemcat may ba foewnrdad to the Depwtzn 2 of IndueAel AoddOO&Ofhoo of Imunnoo for the
coverage vcrificatioa and that failure to Sea=covecago tnoder section 25A of MGL 152 can lead to tbs impoitiot,of c vu=1 patalhcs
oomisting of a fine of up to S 1,500.00 and/or of tip to otx year and civil pcn,11 ics in the form of a Stop Work Ord-u and a
find of S 100.00 a day against me.
For dctmt-�ttso only
permit Number
____Lot#
S p_T]ttltnr;r'fT
G 1
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�Ti1�ON�1/ICES
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8
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reis e'rei Dine mprovement Tom n#actors Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'.CO,MFENSATION J NSURANCEnAFFI DAVIT,(M G.L.,c.>152, §,25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this al
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
Af
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)far,
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner
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 tl
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 homeowne
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall
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 t
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for pers
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
OSfOTfON 1,01- PT O I?ROF<03£D K c ec a lica
e D J - "
New House ❑ Addition ❑ Replacement Windows Alteration(s))RI Roofing ❑
Or Doors 91 1
Accessory Bldg. ❑ Demolition New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 6(-�wae: 02 z5n.� s t�no�t k, c�p�,�g�� w '•,�1��.
d' de)o --
Alteration of existing bedroom IV Yes No Adding new bedroom Yes No - /nck'. '6
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheets
safflf Wew ho s-U t TO- additio/n7to exisfiing o sing cbtriplete ttie fioLlowini7: �`c'
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? I
f. Method of heating? r-cp-ei, d" Fireplaces or Woodstov_es ke"" Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction w ot,d Pr`L 22,�e /
i. Is construction within 100 ft. of wetlands? Yes I No. Is construction within 100 yr. floodplain Yes
r l
j. Depth of basement or cellar floor below finished grade
k. Will building con orm to the Building and Zoning regulations? " Yes No .
I. Septic Tank 7 City Sewer Private well Cit water Su I V
Y pp y
ECONm IERAt� IORIZATfON ED WHEN
O1NE S �E fl�OIRA�CTflRAPPIIBS4irOR (11LO1NG Pf2M1T
----�.m.c ry I
I, P nn..� 1 as Owner of the subject pro
hereby authorize tc;
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agem
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 and penalties of perjury.
Print Name
Signature of Owner/Agent Date
t
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
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 t/
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:
i ( � it I� �-,
ity of Northampton t
Ypilding Department t e,
11212 Main Street e ep
l FEB i1 �'r''L �'' i Room 100 a
Nor hampton, MA 01060
87-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 = SITE INFORMATION
�' This section to�be cgmpleted�by,office '«
11 Property Address:
k `
rl C e f iY3 / 0106 a2
EImSt. District CB District
SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2y.1 Owner of Record:
Mj n
e-I1'1 A'C' )i151,9i!(_, d.I ,,I k.
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
-SECTION.3— ESTIMATED CONSTRUCTION COSTS
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
C'0
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use,O,nl
$ 4dtng PrmtttNu_rntier Date.issued:'.� � -
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x.
t�gnature
Bulltting ComrriissionerLlnsPec#or ofsB4idmgs Dt ,
File#BP-2002-0716
APPLICANT/CONTACT PERSON PRYBYLO ALAN R&MELINDA A
ADDRESS/PHONE 978 RYAN RD (413) 584-2680 Q
PROPERTY LOCATION 978 RYAN RD
MAP 35 PARCEL 047 001 ZONE SR
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: REMOVE&ADD WALL RENOVATE KITCH ADD WINDOWS&DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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 sion
V 2- Z�Z_
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.
"IS RYAN i) BP-2002-0716
GIs#: COMMONWEALTH OF MASSACHUSETTS
':Block:35-047 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0716
Project# JS-2002.1176
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq ft.): 15681.60 Owner: PRYBYLO ALAN R&MELINDA A
zoning: SR Applicant: PRYBYLO ALAN R & MELINDA A
AT. 978 RYAN RD
Applicant Address: Phone: Insurance:
978 RYAN RD (413) 584-2680 (�
FLORENCEMA01062 ISSUED ON:2120102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE & ADD WALL, RENOVATE KITCH,
ADD WINDOWS & DOOR
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/20/02 0:00:00 664 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo