22D-052 30 RYAN RD BP-2018-1069
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-052 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permift,. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# SP-2018-1069
Project# JS-2018-001932
Est.Cost: 58000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Groan: Homeowner as Contractor_
Lot Size(sa.ft.): 13590.72 Owner: O'LEARY JOHN P
Zoning:URA000)/WSPn00y Applicant. O'LEARY JOHN
AT. 30 RYAN RD
Ano[icantAddress: Phone: Insurance:
30 RYAN RD
FLORENCEMA01062 ISSUED ON.-
TO
N: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: O_ 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 $40.00
212 Mahn Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
, rr z ;16 -u;?^ 2Dt) P
Department use only, .
City of Northampton Status of Permit.
Building Department Curb CuVDrlvewey Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
` Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
.- c Peary
APPLICATION TO CONSTRUCT,ALTER,REPAIRE VATE OOR DEMOLIS AljNE OR TWO FAMILY DWELLING
MR i
SECTION 1 -SITE INFORMATION
1.1 Property Address: Dear.ov aunra.e u:c eeti n to be completed by office
ncm>rnvarc, ve owm^
3C yAh Jed Map L Lot D�� Unit
F(��Lh Ce / ` Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tdn 19
Name(Print) � Current Mailing Attleen/32381-300o
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pemut applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee n
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) C+C��i Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature ✓��� ��
Building Cam issionerllnspector of Buildings nate
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Ec
All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Informaron
Existing proposed Required by Zoning
This column m be finel in by
Eicher,Dn'no",,s
.` L: R: L: R-
Rear
BuildingHeight
Bldg, Square Footage
Open Space Footage
(Lot arca in.bldg&Paved
ackin
#of Parkin S aces
volumn&Loca�ion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW O YES 4
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document 7t
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over i acre? YES Q NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Atteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [p Siding[[-31 Other i[:I]
Brief Description of Proposed
Work: rt.p'fi yC roF-
Jt
B
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 100 fl.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 APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner 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 the pains and penalties of perjury.
Print Name / r
Signature of Owner/Agent /`-- Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
City of Northampton
Massachusetts
r
� DEPARTMENT OF BUILDING INSPECTIONS a
212 Main Street a Municipal Auiidv 5 a�
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC').
M.G.L. Chapter 142A requires that the"reconstruction, atteratton, renovation, repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but hot more than four dwelling units....or to structures which are adjacent to such residence or budding"be
done by registered contractors.
Noce:Lf the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Works---X—&4e' '&( Test Cost
Addressof Work: 'S /i y4h, �IOAd �loftn Lt
Date of Permit Application:��1g
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
—Other(specify):,,,,
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
yll�)g r
Date Owner Name bdSignature
City of Northampton
s _
i� - Massachusetts
DEPARTMENT OF BOZLDZNG INSPECTIONS
212 Main rtz • Mw 010 Building JLS V CD
Northampton, MA 01060
Massachusetts Residential Building Code
Section I IO.RS.L2
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 shall not be considered a homeowner.
Section I I O R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
City of Northampton
Massachusetts 3sls -s��c
( DEPARTMENT OF BUILDING INSPECTIONS
310 Min Street *Municipal Boilaing JG�C
�\ Northampton, MA 01060
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:
3aRY4;1 Road
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
A611a 'Zil aff Gc,lftUurJ
(Company Name
/and Address)
Signature of Permit Applicant ner Date
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.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017w
wwmass.gov/dia
V!11
a
11 orkers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organaanon'lndividuap: 77
Address: .IL ! J 12
i
City/State/Zip: L Z Phone#:
Are you an employer?Check the appropriate box. Type of project(required):
t[J l ama empioyerwah employees(fiill anmor pswome)r 7. ❑New construction
2.❑lamasoleproud¢ororpvmerstipmdhavevo®ployeeswod gformem g, ❑Remodeling
y capacity.[No workers'comp.marrence required.]
3;�]ama homrownrdomg all work myself[Nowmikescomp.iasuranocrequueL]t 9. El Demolition
4 1 am a homeowner and will be hiring contactors to conduct all work on my property. 1 will 10❑Building addition
cosim,that all contactors eiwer have workess'exmpemaHon immanne or are sole 11.E]Electrical repairs or additions
proprietors wiN no employees,. 12.❑Plumbing repairs or additions
5r7 I ex u genas]eonhanmr and I have hued the sabnnntractors listed on the mached,bect
near sum-wneaanrs have employees and have workers omp.camorcc. 13.❑Roofrepairs
6.❑We we a evaporation and its officers have exercised their right of exemption per MGL e. 14.❑Other
152,§1(4),andwe have no employees_[No workers'comp.N movere resulted.]
"4ny apphcam Zhao checks box RI must also fill oto Ne section below showing their workers'compm utero policy ivfoamariws,
l Herm who submit Nis affidavit indicating they,are doing all work and then bite er,mo-c contractors ad a submit a new af5davit indicating such.
:Contractors Nm check Nis box most a cripl d an,they mus sheet showing Ne tome oximp soblcontractors and state wheNer or not those rndties have
employees. If the subwntracrors have employeey they must provides Ncu workers'wap_polity vumba.
I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of th4s statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penaldes ofperjury that the information provided above is true and correct
Simamre: g_�_G �� Date
Phone#: ,'��0�` d71�— �JE
Official use only. Do not write in this area,to be completed by city or town official.
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for heir employees.
Pursuant to this statute,an employee is defined as"._every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,ELssociation,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,of the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall.rot because of such employment be deemed to be an employer."
MGL chaplet 152,§25C(6)also states that"every was or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business ur to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into arty contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit con plewly,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),addresses)and phone number(s)along with their eemficatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this of idavil may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the comber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy infomhatien(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for£rave permits or licenses. A new affidavit must be filled out each
year. Where a home owner of citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tet. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 wwu'.mass.gov/dia