35-157 (6) 824 RYAN RD BP-2017-0407
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35 - 157 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
gagaion BUILDING PERMIT
Permit# BP-2017-0407
project# JS-2017-000674
Fst.Cost: $21996.83
Fee:$143.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: THOMAS MALONE 055236
Lot Size(sa. ft.): 47044.80 Owner: RICHT JAMES R&ANNA M TRUSTEE
Zoning: Applicant: THOMAS MALONE
AT: 824 RYAN RD
Applicant Address: Phone: Insurance:
128 RYAN RD (413) 885-9038 WC
FLORENCEMA01062 ISSUED ON:10/6/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:CHANGE EXISTING BEDROOM INTO MASTER
BATH
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 Thai:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY 01?NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature.
FeeType: Date Paid: Amount:
Building 10/6/2016 0:00:00 $14300
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0407 X e//79R"%hip
APPLICANT/CONTACT PERSON THOMAS MALONE eo
ADDRESS/PHONE 128 RYAN RD FLORENCE (413)885-9038 LI
PROPERTY LOCATION 824 RYAN RD
MAP 35 PARCEL 157 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out {ci_
Fee Paid
Typeof Construction: CHANGE EXISTING BEDROOM INTO MASTER BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055236
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
„e;e7
e /etZe
-,,,•.. ao ding dial 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.
8--„n4/ p/ans 7t-o c hac, i
Department use only
r' ),\ City of Northampton Status of Permit
�� \ \ �\ Building Department Curb Cutrtniveway Permit
E't\_________,,,..----
\
„,c \ • 212 Main Street SetvecSepticAvailetMlity
rt`3 r'` Room 100 Water/Well Avalnabiity
5- Northampton, MA 01060 Two Seta of Structural Plans
___,--.-.. . ... phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
V" Other Specify
\„,„..--- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1 Property Address: This section to be completed by office
C m cLy ^ Map Lot Unit
VAUf `tZ. 17141- O t O Ci L Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5LX2. CCD / "y‘'\ \,lcc c1 tty ay, 4-z W\t, mfi-oldoz
Name(Print) Current Mailing Address:
- `ik) - sae-SZZ or 4t3 -381-15)1
,:. - - -_ Telephone
Signature
2.2 Authorized Agent:
r-\Nits Lm„t N M \oet- \Ar- Q-AvUn 21_ hotsGcc m-R-of pb Z
Name(Print) Current Mailing Address:
L\\t) — 3"11037
Signature i Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building it L 63 (a)Building Permit Fee
2. Electrical
1.-000 Oa (b)Estimated Total Cost of
Construction from(6)
3. Plumbing -, a Uo Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �//�
6. Total=(1 + .Z 2+3+4+5) 1ggL. US Check Number fir/V3
This Section For Official Use Only
Budding Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings 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
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot arca 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 0 DONT KNOW el YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW e YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO er
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O'
IF YES, describe size, type and location:
E. Will the construction activity disturb(dearing,grading ex ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(Check all apgllcable)
New House 0 Addition ❑ Replacement Windows Atterationts) y Rotating n
Dr Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [cll Decks ID Siding[O] Other(p]
Brief Description of Proposed 11 tt ` rt'
Work: C...\ nn.( c7
t- .AtTC �t\.c.\K� µ.-•
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 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? m.
d. Proposed Square footage of new construction. Dimensions _
u, Number of Modes?
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 AGEENTT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, J1/4.1t......1-a4+ j '[i 1\ ck)” cc.(-a) ,as Owner of the subject
property
hereby authorize r---cinvQXNC\ C�[.✓�,+y..—
to act onn�y�rb�/ehalf,in all matters relative to work authorized by this building permit application.
xadSignature O
;firmer _.. Date — Z\ b
ttv,.c i< '�\r' .- ,as Owner/Authorized
Agent hereby decare 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.
mti\crR—
PrintNa
Signature of Owner/Agent Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ^r� Not Applicable 0
yv
Name of License Holder: lrAeS ( sc\t)PC,- (mss—0 SS 7 }b
License Number
\ 9x (L. aL F\a1 rt Dl(Wb L 1— ct- —7°'V
Addre Expiation Date
\3 ZS C-co 3�
-•nal - Telephone
9.Registered Home�
meIm`p�rove1ment Contractor. Not Applicable ❑
a\k� r/x�xN aLs. -VINO/ / (1 v k 1,1 5-1T
Company Name Registration Number
(L-L V- vL.lr_ milt- 0Cab Z 16 --1—\b
Address '-r Expiration Date
Telephone.•1/4144-5--cu) I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 V
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 1083.5.1.
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 shalt 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 ander 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
City of Northampton 212 Main Street, Northampton, MA 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: 7 Zct
The debris will be transported by: 'ova,.,, (eV c_
The debris will be received by: \It&
Building permit number:
Name of Permit Applicant V row-.S f\\A k, rC-'
--11.7110 / 9•
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
1x_=___,71 P
ol_ Office of Investigations
__ 1 Congress Street, Suite 100
;Mil Boston,MA 02114-2017
-� www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#: _
Are you an employer? Check the appropriate b : Type of project(required):
1.❑ I am a employer with 4. 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp, insurance comp. insurance.l 9. ❑ Building addition
required.] 5. 9 We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.9 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
"My applicant that checks box al must also fill out the section below showing their workers'compensation policy information.
t homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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. #: 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 verification.
I do hereby certify under the pains and penaltiegiv erjury that the information provided above is true and correct.
Signaturere1Date: CI—ZZ k
'
Phone#: -\\3 $VS—' 9.p
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License It
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#:
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