29-030 (8) 284 RYAN RD BP-2018-0003
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-030 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-2018-0003
Project# JS-2018-000006
Est.Cost: $3820.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SHUMWAY ROOFING 013908
Lot Size(sq.ft.): 13547.16 Owner: CHEA ROEUN&SOVANNARY
Zoning: Applicant: SHUMWAY ROOFING
AT: 284 RYAN RD
Applicant Address: Phone: Insurance:
625 EAST PLEASANT ST (413) 549-4658 0
AM H ERSTMA01002 ISSUED ON:7/5/2077 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP ROOFING INSTALL ROLLED ROOFING
REAR ROOF ONLY
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: O1: 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:
FeeType: Date Paid: Amount:
Building 7/5/2017 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
7 \
Department use only
r/yrr City of Northampton Status of Permit:
s: +" 's,',\'k, Building Department Curb Cut/Driveway Permit. „_
77 1
,r�I,I�� , 3;;
212 Main Street Sewer/Septio Availability
\ t ( 6 �g'+ Room 100 WaterAVell Availability
`` 4 1Y/ ' Northampton, MA 01060 Two Sets of Structural Plans
\ ` :.leis- phone 413-587-1240 Fax 413-587-1272 PIpU$te Plans
"' i Other SPec3ty ,
APPLICATION TO CONSTRUCT,ALTER, REPAIR,R,RENOVATEORDEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6r / "
rtThis section to be completed by office
1.1 Property Address. a 1,1 � Unit
421g
ierce/ /O Map ((N'� Lot
77 1 JG G Zone_ Overlay District_
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
1.1 Owner of Record:
. ,is uN _____,22=36(.� _____,22=36(( Rya[! do
Name(Print) Current(M,/adiry Addre_
r LPA Telephone ` C P7
Sg,tamre
2.2 Authorized Anent:
f¢v/ " . Au _ ' 6.25 I F/en at...r ityki; r
Name(Print) p Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
I rj .5 ht/ lac r e/ (a)Building Permit Fee
!� Msm4' /di/.1rno r
2 iiffifffese ` (b)Estimated Total Cost of
Icglt (UGC este ,,,,, Construction from 6
3 Hbrntrng ll�� / Building Permit Fee
4 M ca (HVAC)
5. F ;•06-_ tion
r ..... .r r
6 Total =(i +2t3*A + 5) -3,S2ea Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued
Signature: _C`^-- t .... 7(3/1 7
0 IC Building Commissionetllnspector of Buildings Date
Ihasbrouck @ northamptonma.gov
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstructionAASupervisor License(CSL)
✓� 1 3 ?og
�6Z t 5 l/ et/ / License Number Expi tion are
Name of CSL Holder
/2S la ��'ei cage I �� CSL Type(see below)
No.and Street T - Description
749 �7497 ,(;.17- �f Unrestricted(Buildings up to 35,000 cu. It.)
7 ,(;.17- !j e 4/PG2— R Restricted I&2 Family Dwelling
City/Town.State.ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registers ome Improvement Contractor(HIC)
Ctf -1{ ,,U /2JntYHI� ta�o�mber pi tion Date
HIC Com aria Name or IIICKaaistrant Name
95- rr
No.and re /U9� o
el i0 Email address
s�
City/Town,State,ZIP Telephone
SECTION 6: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.
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
CONTRACTOR OR OWNER'S AGENT APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize 44, Lx /0//9-y-
to act on my behalf, in alll matters relative to work authorized by this building permit application.
Owner's Signature to
SECTION 7b: APPLICANT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this a ication i ue and accurate to the best of my knowledge and understanding.
Vre
���
Convect /Owner's Aye1/Otmer Signature
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will¢¢t have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www macs nv'oca Information on the Construction Supervisor License can be found at www mass gov(dot
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3 "Total Project Square Footage'may be substituted for"Total Project Cost"
{qty The Commonwealth of Massachusetts
IP Department of Industrial Accidents
, .•i+--mob' - Office of Investigations
or 600 Washington Street
1, Boston,Mel 02111
trr F - www.mass.gov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information 9 Please Print Legibly
Name(Eusinesx/Organiz`atioMndividuual): v 4-47" 1 4, P 1
Address: (�s- .0 _ .- j—
CitylStateIZips yam,•. / �.. = Phone#: _ 6 ,
Are you an employer? Check the appropriate boa: Type of project(required):
1.0 I am a employer with 4. 0 I am a general contractor and I
�'e�mployees(full and/or part-time).* have hired the sub-contractors 6. [�New construction
2.7"L am a sole proprietor o{'partner- listed.on the attached sheet, 7. 0 Remodeling
shi}and lave no employees These sub-contractors have g. Q Demolition
wo for in anycapacity. employees and have workers'
& a c ty. t 9. 0 Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. 9 We are a corporation and its 10.r Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11 Plumbing repairs or additions
myself. [Vo workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.)t o. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that chinks box#1 must also Ell out the section botow showing their Workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contract+orsmast submit anew 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 We suA-conmactors have employees,they must provide their,workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Namr. x/(fj'7'PIEL — .0/ — O. w A — ,7 e/74
{{7
Policy i7 or Self-ins.Lia,Yr: Expiration Date: F I/ +/✓f2 /f x
Job Site Address' 7 / file .G79 City/`State/Zip; �! 4/ Lal /771/2 Or&Oa
Attach a copy of the workers'coin ensatiou policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $L500,00 and/or one-year imprisonment,as well as civil penalties in the formof a STOP WORK ORDER.and a tine
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.
Ido hereby certify under t -pains<. d pert des ofpetjury that the information provided above is true and correct
Sienamra• ! r � �.....�. Date: 0 /
Phone 4: y�r it ... -._
Official use only. Do not write in this area,to be completed by city or town official
City or Town: - Pennit/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#: •
City of Northampton
s •
Massachusetts ,?
bac
l ! DEPARaMnNT OF BUIuDING INSPECTIONS o ® n
212 Main Street *Municipalfpt'‘`'
`Building Fe
ter,y.�s
Northampton,
MMA 01060 V TUB
Debris 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.
The debris from construction work being performed at:
285" /.n i49
(Please print hose number nd street name)
Is to be disposed- by '
Sf{/�rr rPoo/to %n Q./1/We) 7?'o y
(Please print'name and lo ation f facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
• nature Permit Applicant to
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.