35-072 (6) City of Northampton 212 I1/lain Street, Northampton, NIA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: y "i C--� /a
The debris will be transported by: (-C-
The debris will be received by: 7
Building permit number:
Name of Permit Applicant
r
2
ate Signature of Permit Applicant
A
_�ZC NSPECTI
O�F BUILDE, - L 10-NS
,7
!NSPECTOP 212 Strut 0 Municipal uildmg
Northampton, MA 01060
Y-T,-N N XT71 rNVWN7'V I) V'%r-V N4-D'rMNT A IV7\7nWT VJ)(_TFA4F7Vr
The State of Massachusetts allows the homeowner the ria.112t, under 780CNa 108.3.4 to
s- rson(s)
act as iris/hoer Construction Su _or. The stare defines "Homeowner" as, "Pe,
who owns a parcel on which he/she resides or intends to be, a one or two family
ravelling, 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
home owner."
The building:department for the City of Northampton wants any per who seek to
use the home owner exemption, to act as Lie,:,-own constracito-n supenriso-, to be aware
that by doing, so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backTI111).
sonotube holes (before i)our) a rou<zh building inspection (before work is
_car cezIS:S
J). i-nsulatio-n insT)ection (if reauired)-and-a-rinaLbuildin-g.insnection. The
building department requires these inspections before the-work is conceal-ed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the-work can-be inspected.
If the homeowner hires other trades to perform work(electrical, gas
plumbing.,&gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the buildinc, permit issued, and that they get their required
ID rM
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above-
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
`g 7-he Commonwealth of Ylassachuserrs
-- Jepat-tmeni of Industrial Accidents
^' Q tce of f Invesnga:ions
` 600 W ashingron Street
ter AL-1 02111
www.mass n ovldia
Workers' Compensation Insurance Af_ida`it: Builders/Contractors/Electricians/Plumbers
Apalica.nt Information Please Print Lesibly
Nable (B-siness/orgzmization/IndividuaI): q w e e r �C�C�t,a3�/L ,S lei
Address: ..� c� h Q,' C>_
City✓`State/Zip: a t 3 o i Phone. : '�� •�Y ? 9 (a 9
Are you an employer?Check;the appropriate box: Type of project(required):
4. I am a gene'-a.l contractor and I
1.7 I am a employer with � 5- ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
ice, r_ -listed on the attached she_: � � 7. XRemodeling
f '='l 1�a sore proprietor or partner- I
1 shivp and have no!!=loy ees These sub-con=ctors have g_ Q Demolition
wor Q employees and have work_rs'
� for me m any capacity. � ` 9. Building addition �
N wore' c �.�.ins- ance come.��ance.*
require-d-1 5. 7 We are a corporation and its 10_❑
Electrical repairs or additions
3.7 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.Q Roof repairs
insurance required_]t c. 152, §1(4),and we have no
employees. [No workers' 13.7 Other
come.insurance required.]
- ---" av mpg ican tie t�ooz�. itnist a so u out me swan oe.ow snowm� eff worlce s con>pensanon poucy mforn=on.
'.z1oMeownen;who submit this afIIdavit indicating they are doing aD wort:and then hire outside contractors must submit a new ainaavit indicating such_
:contractors that cheek this box must.attached an additional sheet showing the narne of the sub-cannactots and state whether ornot those entities have
empiovees. L`the sub-contni=rs have employees,they must provide tbeh• workers'comp.poncy nut.
I am an employer that is providi'jz,workers'compensation insurance for my employees: Below is the policy and job site
informadon.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: - City/State/Zip:
Attach a copy of the wormers' compensation policy declaration pace(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 a.n6or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fne
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
In vesti__^adons of the DLk for insurance coverage verification.
.f do hereby cerd der the pains an penalties of per'ury th the informadon pro id, d�+abov is tr and correct
Phone r:
t _ '
LOtber e only- �n not x rate rn th area,t�be conzplered by cif t ur raven ofj'iciat
wn: -- _ - ___ -_ -Fer-mit/License
thority(circle one):
Health 2.Buildinj Department 3. Citv/Town Clerk: 4.Electrical Inspector S. Plumbing Inspector
son: Phone T:
i
y
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: W �ce-� J y
License tuber
�R? 0( S Do VVL W C) 7-3 ) 1 5'
Address Expirati n Date
--z, 09�&,
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
0.r.J e 2 �) e L L W a �I-� C> f3 t� `d d C7
Company Name Registration Number
Address J Expiration 91te
Telephone Y1 �, 0?V) ?2�
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 building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. -Home Owner Exemption
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-vear 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 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[:] Siding [p] Other[
Brief Description of Proposec !_
Work: �e-pn n a- /C �fJ�- 1 N/l�®�PY- 0--J e Cc KJ� 1'C!*440110
Alteration of existing bedroom Yes );'*' No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes !t No
Plans Attached Roll -Sheet
6a.if New house and or addition to existing housing, complete 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?
i I
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 baserrient 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 7d -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize Wt' y�
to act my behalf, in all matters relative to work authorized by this building pe it application.
G �- 1s
Sig ure of Owner Dat
I, G 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 and penalties of perjury.
Print Name
Cc—
Signature of Owner/Agent Date
t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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
oarkin2)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES 0
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 ,X, DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 Gonstri intinn artivity disturh(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
k
(� (� r r� Department use only
KEIec �l City of Northampton Status of Perml#.
Building Department Curb Cut/Driveway Permit
20212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability
um 'n?s Northampton, MA 01060 Two Sets of Structural Plans
ort p.4an 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specifyi
i
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
R4 y�� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'"raurvl a Q - �!-s y rya
Nam rint) Current Mailing Address:
/✓ 7 4! -R -
Telephone
S(/ature
2.2 Authorized Agent:
ft)1 � ��- 2 c14/ L 0-3 Ij/5Do -A Rk 0 13o i
Na rint) 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 �*�r (a)Building Permit Fee
2 Electrical / VC) (b)Estimated Total Cost of
cs� Construction from 6
3. Plumbing / d C) Building Permit Fee
4. Mechanical(HVAC) t�
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
—
Building Commissioner/Inspecfd-r OfBw mgs Date
File#BP-2015-1287
APPLICANT/CONTACT PERSON WILLIAM CHILDS
ADDRESS/PHONE 229 WISDOM WAY GREENFIELD01301 (413)247-9269
PROPERTY LOCATION 884 RYAN RD
MAP 35 PARCEL 072 001 ZONE
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:_REMODEL BATHROOM&INSTALL KITCHEN REPLACEMENT WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 014572
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
pproved 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 Commission Permit DPW Storm Water Management
Demol' ' n Delay
Sign re o ui mg 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.
884 RYAN RD BP-2015-1287
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -072 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catego!y: renovation BUILDING PERMIT
Permit# BP-2015-1287
Protect# JS-2015-002370
Est.Cost: $6425.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM CHILDS 014572
Lot Size(sc. ft.): 19994.04 Owner: KABAT HENRY F&JANE H
zoning: Applicant. WILLIAM CHILDS
AT. 884 RYAN RD
Applicant Address: Phone: Insurance:
229 WISDOM WAY (413) 247-9269
GREENFIELDMA01301 ISSUED ON:611612015 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM & INSTALL KITCHEN
REPLACEMENT WINDOW
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 Siznature:
FeeType: Date Paid: Amount:
Building 6/16/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner