22B-048 (3) City of Northampton 212 .Main Street, Northampton, Na 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, 1 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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Sign-ature of Permit pplicant
City ' of Northampton
Massachusetts
r DEPARTMENT OF BUILDZI�G INSPECTIONS ✓ x,"
Y
1` 212 Main Street • Muniq:ipal Building
Cr-
`�;n^ Northampton, MA', 01060 1ss�,� .
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXENIPTIONI ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants) any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, 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 ijispect work at various stages, which include
foundation/footings (before backfill) sonotube holes (before pour) a rough building inspection
before work is concealed insulation inspection if re uired and a final building inspection.
The building department requires these inspections before ihe work is concealed, 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, plumbing & gas) the homeowner will be i
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required 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
l 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
4ddress of work location
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The Commonwealth of Massachusetts
Department of Industrial Accidents
} Office of Investigations
600 Washington Street
F .Boston, ALL 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatiogn Please Print Legibly
Name (Business/Organization/Individ 1):
Address: Yb/
City/State/Zip: Phone#:
— 4LR 1�
Are you an employer?Check de appropriate'lox: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees (full and/or part-time).
have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp, insurance comp. insurance.$
required.] 5. F_� We area corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12ZRoofrepairs
insurance required,] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: b-S Z� iration Da�:
Job Site Address: City/State/Zip:
Attach a copy of the workers co4ensation policy declaration page(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 $1,500.00 and/or one-year imprisonment, as well as-civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do here rdfy under the VWA,9 andpenalties ofperjury that the information provided above is true and correct.
Si afore Date:
Phone-
Of
icial use only. Do not write in this area, to be completed by city or town of
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 87 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
�� Not Applicable £
Name of License Holder: 'l WI► Ic
License umber
Address 2 Expiration Date
iA [( a(11(4 r I Jofi,
J
Signa r Telephone
9 `RegisferedHomeamprovementContract or.
Not Applicable £
S
Company Name Regis ration um er
Address Expiration bate
Telephone 35 v
SECTION 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.-.152,§25C(6))
Workers Compensation Insuran e affidavit must be completed and submlitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of e building permit.
Signed Affidavit Attached Ye ....... £ No...... £
11 Home awner.Egenption'
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 cjr detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in la 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 build inejpermit.
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 Stafie of Massachusetts General Laws Annotated.
Homeowner Signature,
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[2] Decks [❑ Siding [0] Other[0]
Brief Descripti of Prop o ed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If`New.hause artd_oraddlt�orfto eXisttnq:housng, complete the foalowl:ng:
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. 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 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 APPLIESTOR BUILDING PERMIT
I, t t 1 � as Owner of the subject
property _ L
hereby authorize
to a n my behalf,In all matt rs relative to work au orized by this building permit application.
Z22
Si at re of Owner Date
I, f Ili as Owner/Authorized
Agent hereby declare that the statements nd information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pai�s and penalties of pe jury.
Print Name
/0 �
Signature of Ow6-r/A6ent Date
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 I ----} --
Setbacks Front
Side L:' 1 R:` r L:! R:= r�{ --a'
Rear
Building Height
Bldg. Square Footage + L % �C r
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: f `
r
(volume&Location) =------i A. Has a Special Permit/Variance/Finding ever beerh issued for/on the site?
NO DONT KNOW Q YES a
IF YES, date issued: j
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Pi�igel and/or Document#s
B. Does the site contain a brook, body of water or wettands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: f
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q
IF YES, describe size, type and location: j
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that wfff disturb over 1 acre? YES O NO Q
IF YES, then a Northampton Storm Water Management Perrinit from the DPW is required.
i a
FROE A ED - pepartment use only
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Ity of Northampton Status,ofPermrt �I
uilding Department ;Club CurEDri+[eay Perrrii#E
9 ?f�15 212 Main Street Sewer/SeptPeAvaiRoom 100 No hampton, MA 01060 tt'ictural NG 1.SPFvTtONS _ _,: - .r=_y
- 87-1240 Fax 413-587-1272 vPIoflSlte Plans
;ether Sp:eci}!
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION:=
This section tgm be completed by office
1.1 Property Address: -
Zone- �__ Overlay Disfrict -�.
EIm St;District —=::= CB Distract
SECTION 2.-PROPERTY OWNER..SHIP/AUTHORIZED AGENT
2.1 Owner of Record: _ y
Name(Print t Current Mailing Add"
Telephone
Signature /
2.2 Authorized A ent:
Name(Pr' Current Mailin A dress:
�- r 33s= E
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 1 (a) Building Permit Fee
2. Electrical v (b) Estimated Total Cbst 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
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Bui ldings: , Date
15 RYAN RD BP-2016-0600
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22B-048 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0600
Project# JS-2016-000999
Est.Cost: $1800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM LYLE 105508
Lot Size(sg. ft.): 12980.88 Owner: BANK OF NEW YORK MELLON C/O KONSTANTINOS SIERROS
Zoning: WP(99)[WSP(99)[URA(66)/GI(32)/ Applicant: WILLIAM LYLE
AT. 15 RYAN RD
Applicant Address: Phone: Insurance:
1851 NORTHAMPTON ST (413) 533-6012 WC
HOLYOKEMA01040 ISSUED ON:1012912015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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:
FeeTyge: Date Paid: Amount:
Building 10/29/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner