22D-026 198 RYAN RD BP-2019-0118
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Blmk:22D-026 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv-renovation BUILDING PERMIT
Permit# BP-2019-0118
Proiect# JS-2019-000195
Est.Cost $50000.00
Fee:$325.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group Homeowner as Contractor_
Lot Size(sp R.): 15071.76 Owner: DRISCOLL BRIAN D&CHRISTINE L FARRICK
Zonine:URA(1001/WSP(I00)/ Applicant., DRISCOLL BRIAN D & CHRISTINE L FARRICK
AT. 198 RYAN RD
Applicant Address: Phone: Insurance:
198 RYAN RD
FLORENCEMA01062 ISSUED ON.7/31/2018 0:00:00
TO PERFORM THE FOLLOWING WORK FI NISH SPACE -ADD MASTER BATH AND 1/2
BATH, CONVERT 2 BEDROOMS INTO LARGE MASTER BEDROOM
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 Occuoancy Sieneture:
FeeType: Date Paid: Amount:
Building 7/31/20180:00:00 $325.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0118
APPLICANT/CONTACT PERSON DRISCOLL BRIAN D&CHRISTINE L FARRICK -
ADDRESS/PHONE 198 RYAN RD FLORENCE
PROPERTY LOCATION 198 RYAN RD
MAP221)PARCEL 026 001 ZONE URA J l00VWSP(100)(
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATIO14 CHECKLIST
D REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: FINISH SPACE-ADD MASTER BT ND1/2 BATH CONVERT 2 BEDROOMS
INTO LARGE MASTER BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accesscuy Structure
Building Plans Included'
Owner/Statement or License
3 sets of Plana/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 UNDERi.
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
7
a re of Br Idmg tial Date
Note:Issuance of a mog permit does not relieve a applicanPs 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.
Departmairtum t## 1110&:
City of Northampton Still a'
Building Department cult Pam "'JOW MwO
p Awfla 01 is jllw
212 Main Street
Room 100 fismilabift :K; 14 111l'
Northampton, MA 01060
,I es:o'
phone 413-587-1240 Fax 413-587-1272 its
Other=TY
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION &�7-14—//S?
1.1 Property Address This section to be completed by office
1,21 41w FO. Map �2 6-2rw
— Lot o)41 u —
'70
Zone_Overlay District
Ekin St.District CE Distinct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT I
2.1 Owner of R cord:
CARA,(— )qq F-1ANI-N . EA%::.mrrAAAlp ,:.2--
cimant mqp-Tilss dqs--16-7. 01�
X
Telephone
Signaturs
2.2 Authorized Agent,
let aG 1L
Current lvlanliAddress:
I Z 2z
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars)to be Official Use Only
completed bertnitatiolcant
1. Building 13 0-(30 (a)Building Permit Fee
2. Elect-cal (b) Estimated Total Cost of
Construction from (6)
3, Plumbing o Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 6 Check Number
This Seam For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedinspector of Buildings Date
UjddI*t?' 0010 1- @
X EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
eowR""k em A-) U - &,014409k - 11-0M
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 m by
Buildiag Depmunemt
Lot Size
Frontage — .—.... ....._"
Setbacks Front -'- --"
Side L. .... R:. .-_ L:_ R:-
Rear Rear _..
Building Height
Bldg.Square Footage % — ---
Open Space Footage % _..
(Io'arca
#offarking Spaces -- -
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding r been issued for/on the site?
NO O DONT KNOW YES O
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#
B. Does the site contain a brook, body of water or wetlands? NO 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 O , Date Issued:
C. Do any signs exist on the property? YES O NO E)
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing grading,excav n, orfilling)over 1 acre or Is it partof 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 5-DESCRIPTION OF PROPOSED WORK(check all aoofigablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) E:1 Roofing ❑
gr Doors
Accessory Bldg. ❑ Demolition LJ New Signs [[J] Decks [0 Siding [O] Other[Of
Bnef De ptton of Propos d /'
Work: �i &'Upye .Siva- JF/gr WAs l7EneL�/HAN � ERfS�Cro
Alteration of existing bedroom ✓ Yes_No Adding new bedroom Yes -'� No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
lig N New house and or addi tion to existing housing,complete the following:
a. Use of building: OneFamili Two Family Other
It, 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 APPLIES FOR BUILDING PERMIT
1. as Owner of the subject
pmpe
hereby au on
to act o y b hal, in all ive to work authorized by this building permit application.
Signature of Owner Date
I, (Lti Q#t -DaL:�,Go lit✓ 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.
11144 Co
Print Name 0 �
iii
!iL
X S g ature pf Ow er/Age Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
No..of License Holder:
License Number
Address Expiration Date
Signature Telephone
8i t d Home 11 wmeCOMIC!", - Not Applicable ❑
Ea�#AVy2ElL l9/SSR
Company Name Re istradon Number
N S-`2 .0
�j �7 ,Eyepiration Date
1'1 B�l6Q W/7OD dX_ YJV(G Telephone J ZO
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ill 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
DB12 iaam S OF B0 LDINGMunicipal
INSPECTIONS
212 191n ruse, • Num, 011 Bui1d3N9 X31 0G
Northemptoq ta, 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, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing ownerbccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by rezistered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered
,,l
Type of Work: I.�lax ?,CtsWVAT(!►.A y�Est. Cost: 6-0 '"o
Address of Work: 19 S -/pN2A 6I� ey I-I�/ 0(pL
�
Date of Permit Application:
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 h eby a ly for a building permit as the owner of the above property:
Date Owner lqame an gnature
n
City of Northampton
taE96dChll99tt9
� I
DEPART T OF BUILDING INSPECTIONS '
212 Main Street • Municipal Building yJLly� � Fb
Morthu ton, . 01060
Massachusetts Residential Building Code
Section 110.115.1.2
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 110.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 1 IO.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.
i
City of Northampton
, .
Massachusetts
G
Z
DEFARTIIENT OF BUILDING INSPECTIONS
212 Nein St—t •lNnicipal Buildinq 2J` CD
Northampton, l 01060 SYH. VnB
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
/9S " ]pb.
( ease pant 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:
fI/�IHFQS'f QLf ►Al
(Company Name and dress) 4
Z s/� 7 - 30 - /S-
Signature offer pplicant or Owner 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 of Industrial Accidents
7 Congress Sheet,Suite 100
Basion,MA 02714-IOI7
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:BuildeNContractorsiElectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name(Businasrorgmn atiowlndividuap:
Address:
City/State/Zip: Phone#:
Are you an employer". Check Ile approprhom box:
Type of project(required):
L[:]l am a employer with employees(inn and/or parttime)' 7. ❑New constNetion
2❑l am a sole proprietor or fmmership and have no employees working rot me in $, y remodeling
an�yocartacity.[No workers comp,donations, required]
3.[]I omeowncr doin II worker if No workers'cum .isurnc d 9' []Buildin ion
rC''IT/ g a myself[ p insurance require ]'
4. homeowner and will be hvin l0�Building addition
g workers'C m conduct all work on my property. 1 will
that all wnbacmrs either have workers'mmpensmipn nsumnre or are solell.�lectrical repairs or additions
pmpriemn with no employees 12.r5rKumbing repairs or additions
5 I ern a general commoner and l have hired the sub-conaectors listed on the ranched sheer 1},Roof repairs
Thse esub,,mormuors have employees and have workers'cramp.insurer
6, We are a empomtion and its officers have exercised their right ofexemption per MGL c. 14. Other
152,p Iffi,and we have no employee,.IN.wohers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below shown,them workers'compcmmion policy information.
'Homeowners who submit this affidavit managing they arc doing all work and men hire outside cootrmorm most submit a new affidavit indicating such.
Kona e.thoucheck this box most attached an additional sheet showing the name ofthe subcmarm.and was,whether or not those entities have
employees. Ifthe sub-co means how,employees,thry most provide their workers'comp.policy number.
I am an employer that is providing workers'eampenwaaon insurance for my employees Below is the police 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 polity 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 a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u/n/it the p i andpen ' s ofperjury that the information provided above is true and correct
S,, future /3— Q Date
Phone#
►►rrrr�� 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their 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,association,corporation or other legal entity,or any two or more
ofthe foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or 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 not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or 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 any contract for the performance ofpub]ic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,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 certificate(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 affidavit 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 number 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 petmir icense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lab 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 future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or 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
Tel. # 617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their 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,association,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, or 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 not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or 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 any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLCM or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance. Han LLC or LLP does have employees,a policy
is required.Be advised that this affidavit 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 number 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 permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fmm Revised 02-29-15
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