29-112 (4) 608 RYAN RD BP-2019-1092
GIS#: COMMONWEALTH OF MASSACHUSETTS
Maw, lock:29- 112 CITY OF NORTHAMPTON
Lot:-001 - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cateenrv: ROOF BUILDING PERMIT
Permit4 BP-2019-1092
Project# JS-2019-001777
Est Cost: $5000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO.
Const Class Contractor. License:
Use Group STEPHEN CAMP 082531
Lot Size(sp.11.1 14984.64 Owner: NIEDAL BERNARD V
Zonin : Applicant: STEPHEN CAMP
AT.- 608 RYAN RD
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527-7124 0 WC
EASTHAMPTONMA01027 ISSUED ON:4/3/2019 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE FRONT 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: 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 Signature:
FeeType: Date Paid: Amount:
Building 4/32019 0:00:00 $40.00
212 Main Street,Phone(4 13)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Depar"use ony
-- City of Northampton Status orp"
-y^ Building Department Our,CullOnnsaway Permit
' 212 Main Street Se"rfSepecAygla4 y
Room 100 Wate4YYellAvailabiGty
` Northampton, MA 01060 Two3ets of Structural.Plans°
phone 413-587-1240 Fax 413-587-1272 Plotsbe Plans
Dtty '
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION b Iq
1.1 Property Address'. This section to be completed by dace
1
Map a Let ' (ma
e. Zone O reday Distad
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
22..11 wner of Record: �j,/ J 1 AX
l�a
Let ,
Name(Pnnt) ' Current Mail irss:
Telephone r�TY%/
Signature
2.2 Authorized Agent:
Name(Pont) Current�M✓ailing Atltlresls.
J 2? ( l ZZ
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by oermit applicant
1. Building (a) Building Permit Fee
aDG�.
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
5, Total =(1 +2+3+4+5) QOO. Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued: ,,11
Signature: q-3-Zo lq
Building Commissioneolnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This uoluma to be filled in by
Building Dcpamnent
Lot Size ...... ...... ._
Frontage
Setbacks Front
Side L R: L:._ R _.... _....
Rear _...
Building Height
Bldg.Square Footage % --
Open Space Footage %
p.ot area minus bldg&Paved --
Parking)
#ofParlung Spaces -- --
Fill:
volume&LocatiorJ
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O 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 O DON'T 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
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(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Sterni Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all aoulicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doo s 0
Accessory Bldg. ❑ Demolition ❑ New Signs I01 Decks [0 Siding[0] Other[C31
Brief Description of Propos d y�
Work: �'
Alteration of existing bedroom_Yes No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished basement Yes __�_ No
Plans Attached Roll -Sheet
Ba.If Newhouse and or addition toexistina 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 heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
I. 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]a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Sig nature of Owner I / /� Date
I, ��{�/„( / ('.a4.,o as Owner prized
apt hereby de lar.that the statement amd information on the foregoing application are true and accurate,to the UEst o edge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature OwnerlAgent ate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SS...rvisor. Not Applicable C /)
Name of Licence Holder:
Y v License Number^
//-27-/9
Address E irunm Date
Signature Telephone
9.Registered Home Imorovemem Contractor: - Not Applicable ❑
Company Name Registration Number
i 3�L�a
Exp tion ate
/�J1W� Telephone J-0
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 a(ftlavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts
h c
m
DEPARTMENT OF BUILDING INSPECTIONS
1n
212 Nnstreet 6• nunicipal Building
Norihempton, `.fA OlOfiO
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 owner-occupied 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 registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est. Cost:
Address of Work:
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 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
_ City of Northampton
s,-
' Massachusetts
c
DEPARTMENT OF NDILDING INSPECTIONS Y
212 Main Street • Municipal Building vi' C
\.:. Nartha tan, M 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 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 110.115, 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 thejob 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 perforin work for you
under this permit.
City of Northampton
6 _
Massachusetts
x
y t DEPARTMENT OF BUILDING INSPECTIONS
212 Main BtO aMunicipal Hullding Cb
Northampton, !A 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:
(Please print house number and street name)
Is to be disposed of at:
1/"11417 l?L���/w //O✓��� / 5'
(P ase print name and locabon of facili
Or will be disposed of in a dumlpster onsite rented or leased from:
//II�Lt� T�C.i9Lr�/ /X✓H�.l�/
( ompany Name a Address)
_fig & /f
Signature of Permit Ap i nt or Owner ate
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
I Congress021 Suite 100
Boston,MAA 02II4-2017
www.massgov/dia
R orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print L o bl
Name(Business/Organization,lndividual):
Address �L ',4S-�
City/State/Zip: t Ani Jo/oz 7 Phone#: T2-7 - 7/Zy
Are you an employer.Check the appropriate box: Type of project(required).
I�am u employer with_employees(feu and/or pmmail 7
-- .' ❑
New construction
2.❑lmu sole pmprie[ororparords,andhave no employees workingurnom $ E]Remodeling
any capacity.[No workers'cmnp.insurance dammed.]
3.❑ 9. E]Demolition 1 tort a homeowner doing all work myself[Nn workers'comp.insurance required.]'
4.❑I am a homeowner and will be hiring cpalrcrors to conduct all work on my,property. I will 10 ❑Building addition
ensom mat an contractors rimer have workers'-innervation wurance or are sole ll.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5 I am asocial b-comcontractor and 1 have hired the have
works'Won listed on the amJred sheer.
'I hese sub-contractors have employees and M1nve workers'mmp.insurance: 13. oof repairs6.❑W'e area carts a[ion and as offices have exercised them right orexemption per M1IGL c. 14. Other
152,p'I(4),and we lave m cunployecs.[No woderscomp.inmmnce required]
'Mv applicant that checks box NI must also 011 am me section below showing their workers'compensation policy information.
I Hormawners who submit this affidavit indicating my are doing all work and then him omsidc contractors must submit a new affidavit indicating such.
:Conaactor that check this box most attached an additional sheet showing the wme of the sub-comramom and sere whether or not thou entities have
employees, If the sub<xammmm howd employees,they must preva a rev workers'comppolicy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. qp " �
Insurance Company Name: /y{� 1)4 +; t�
Policy#or Self-ins.Lic.#: S(� 2 vll -5W1,9
5W 10'j 7 Z Expiration Date: 9
Job Site Address: ° �4 eys City/State/Zip: -
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex tra[ion date).
Failure to secure coverage as required under MGL c. t52,425A 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certi(fft under tlhe/pa' ss and penalties ofperjury that the information providee�d above is nue and correct
Signature: li- � - S�3' Date'
Phone# #-Z7-21*� T
Oficial 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 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, a25C(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 of this 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-contractors)name(s),address(es)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 permit/license applications in any given year,need only submit one affidavit indicating current
policy information(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 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-MASSAFE
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 deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner ofa 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 orbuilding 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 mut 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(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, or 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
most submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe 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(io. 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
I Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Foon Revised p2-23-t5
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