29-152 (11) 519 RYAN RD BP-2016-1135
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 152 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1135
Proiect# JS-2016-001946
Est. Cost: $9500.00
Fee: $64.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(sq. ft.): 959191.20 Owner: NORTHAMPTON REVOLVER CLUB
Zoning: Applicant: PAUL MCCUTCHEON
AT. 519 RYAN RD
Applicant Address: Phone: Insurance:
134 EASTHAMPTON RD (413) 584-3352 O
WESTHAMPTONMA01027 ISSUED ON:4/11/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 8 X 40 SHOOTING STRUCTURE
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 Sitnature:
FeeType: Date Paid: Amount:
Building 4/11/2016 0:00:00 $64.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2016-1135 �0 N IQ fA-
APPLICANT/CONTACT PERSON PAUL MCCUTCHEON
ADDRESS/PHONE 134 EASTHAMPTON RD WESTHAMPTON01027(413)584-3352
PROPERTY LOCATION 519 RYAN RD
MAP 29 PARCEL 152 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid %1,wo af
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 8 X 40 SHOOTING STRUCTURE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinp,Plans Included:
Owner/Statement or License 062544
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 9RMATION PRESENTED:
__. proved_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
Demolition Delay
S ure of B uihimrOffifcial 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.
qL
Versionl.7 Commercial Building Permit May 15,2000
R " Department use only
Ity f Northampton Status of Permit:
uil ng Department Curb Cut/Driveway Permit
LIAR 2 S 21 Main Street Sewer/Septic Availability
' oom 100 Water/W611 Availability
r Northanhpton, MA 01060 Two Sets of Structural Plans
- phone 413-587-1240 Fax 413-587-1272 Plot/Site Pians
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
w -l ve" .. '"�"� Map Lot Unit
'n P Zone Overlay District
__ _....... _..__.. Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
44 OkO61 '
Signature Telephone
2.2 Authorized Agent:
f
Name Print Current Mailin Address
Signature Telephone Lq
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical rn` (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
ued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE t
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description I`;Enter a brief description here. A Q j
Of Proposed Work:., �SA'
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A AssemblyA-1 ❑ A-2 ElA-3 ❑ 1A El
❑ A-4 ❑ A-5 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility E-1Specify:
_ .......... _.._. ... .....
M Mixed Use ❑ Specify:
S Special Use Specify v
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
... ._ .._
Existing Use Group: ...... Proposed Use Group: .__ .
Existing Hazard Index 780 CMR 34):i. Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf)
i
1st
st _..:
nd 2nd -
2 .....
....... ................. .......__.........._........._.......... .._.._..... ...
3rd
3rd : _,... ._.. _,_r.._ ._...
_...,_ _,__...._ _.... .., 4th
4th
..................._.._.._.............__........................._............._..................._........._..:
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft) f
i '
Total Height ft �.\... .......
7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑
I
i
Versionl.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
'O <14CZ
Frontage �'� }
Setbacks Front
Side L: R:>:` L: R
1_
Rear .
Building Height
Bldg. Square Footage } %
=—y
.Lr 1 � .� f..
Open Space Footage %
(Lot area minus bldg&paved r t R'
parking)
#of Panting Spaces
Fill:
(volume&Location) d ,,, .:.:. .
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES Q
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 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
........... --------- .
Needs to be obtained ObtainedQ , Date Issued
_...
C. Do any signs exist on the property? YES , NO
IF YES, describe size, type and location: F=nom
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO t
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, exc vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
_.
Name Area of Responsibtlity
Address Registration Number
Signature Telephone Expiration Date
__.. ... .._....._...... _......... . . ............. _ ...._... ._. ..
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
._.... ........ .
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
_._..... ..__._...... ..._..__.. __.. ._..._...... ...........
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
/ JJ j, t
CADD
Not Applicable ❑
Company Name
Responsible In Charge of Construction ......
,
Address
Signature Telephone
i
II
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
- - - -- - as Owner of the subject property
hereby authorize I Q .._. , �` to
act on my behalf, in L matters relative to work authorized by this building permit application.
71
Signature of6 wner 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.
Signed under_ pains and penalties.of perjury.
...... - _
Print Name
n
S
Signature of Owne/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction u ervisor: Not Applicable ❑
Name of License Holder _.1. �.__ ... .._..yam `. ... C�^.. __.' 7
License Number
Address Expiration Date
Signature Telepho e
SECTION 13-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 0
The Commonwealth of lllassachusetts
4,
Department of Industrial accidents
Office of Investigations
600 Washington Street
.Boston, MA 02111
_ www.rnass.govldia
Workers' Compensation Insurance Affidavit: l uilders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leffibly
Name(Business/Organization/Individual): U _
Address:-! 39
City/State/Zip: Phone#: y r
Are you an employer?Check the appropriate box: 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. m a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
V�aSTZip and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, employees and have workers' Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. 7 We are a corporation and its 10.❑Electrical repairs or additions
D.❑ I m a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t C. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
Homeowners 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 nam 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 far my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation 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 verifcation.
I do.hereby certify i4er the poi and penalt' s of perjure that the information provided above is tr a and orrect.
Siznature: Ali' Date:
Phone#: J -3-3,
Official use only. Do not write in this area, to be completed by cioJ or town official
City or Town: Permit/License#
i
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.PIumbing Inspector
b.Other
Contact Person: Phone#:
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