22-021 (5) BP-2021-2230
239 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22-021-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2230 PERMISSIONIS HEREBY GRANTED TO:
Project# BP-2017-0931 Contractor: License:
Est. Cost: 18886 THOMAS MALONE 055236
Const.Class: Exp.Date:01/18/202201/18/2022
Use Group: Owner: TIATOUM SHONNA M & RANDA H
Lot Size (sq.ft.)
Zoning: WSP Applicant: THOMAS MALONE
Applicant Address Phone: Insurance:
128 RYAN RD (413)885-9038
FLORENCE, MA 01062
ISSUED ON:11/29/2021
TO PERFORM THE FOLLOWING WORK:
PARTIAL RENO IN BASEMENT WITH 1/2 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 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.
Signature:
. . cPAIT
Fees Paid: $123.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts liw 20�1 /FOR
Board of Building Regulations and Standard$T 0,,
Massachusetts State Building Code, 780 CMR'/z";%/n,,,, MI3NIFOR/ TY
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Building Permit Application To Construct, Repair,Renovate Or De Z'InZN� ised filar 2011
One-or Two-Family Dwelling '- "
This Section For Official Use Only
Buildin Permit Number: es?I""-1-)3 Date Applied:
ev,►� �55 ,/ -. ll-Zci-ZOZJ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address:
dress:: 1.2 Assessors Map&Parcel Numbers
-2 -a.1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
cLA c, tiNL'* 6 Nis 4A.\wreA F1 fr,,-t-e. (V\N otoL Z
Name(Print) City,State,ZIP
3 Y1 Ne„ Q.. L, t-►x 3-Li sc-3)33
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
V 0 Q c-t•Sri`(A renO►1A es\ ,n c 4 st'ne"\ w Arin 11-z ( t4-h-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fee : $
Suppression) a1
c Check No.9U /OCheck Amount: a) Cash Amount:
6.Total Project Cost: $ ,7, 6 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
3 C) 1—I g- 262 Z
Thv�c,� (W.V.)fvC License Number Expiration Date
Name of CSL Holder , t
\a Tc Z, List CSL Type(see below) V
No.and Street /� (Xp 4.)' D Type Description
\ Unrestricted(Buildings up to 35,000 cu.ft.)
Cc\c/n,State,ZIP UN1 t Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
_ 1 SF Solid Fuel Burning Appliances
' jtr45,.\ t- I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
(kr HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name Q
No.and Street - Email address
V-‘L CL - (Yc U\019 -c,c3 C
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.
Signed Affidavit Attached? Yes ❑ No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize \ rcXw. m61urt.
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
<. i\(\k\c � \\—Z9-107, I
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
.
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CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
\\\\/
SIDE YARD / SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
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Massachusetts ,4,; -- e,
it,'
i V #.., DEPARTMENT OF BUILDING INSPECTIONS %
w ram ` 212 Main Street • Municipal Building I.
c,
r' Northampton, MA 01060 'r'Jfr „3r
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: \f \ It1-4A('\)
The debris will be transported by:
Name of Hauler: ---\---\ O > WV,\04`(-�
ZZ-
Si nature of A licant: Date: \ --Z' l -v1'
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The Commonwealth of Massachusetts
t'_*._ l 1. Department of Industrial Accidents
;��,r_. 6 1 Congress Street,Suite 100
'�?;_=- • Boston.MA 02114-2017
_,,1.*` www mass.gov/dia
11 oaken'Compensation Insurance Affidavit:BuilderslContraetorsIElectri cinnsdTlumbrrs.
TO BE FILED WITH JUL PERMIITING AIITHOlt1'fl'.
Applicant Information � ` Please Print Lreibls
Name(BasincsssOkkan�stimi lndividual): (.`'l\ - S‘cc(f `l" •(
Address: V 0--1(---• '0.--
City/State/Zip: W(;loZ Phone#: �{k3 s �Are y.0 an employer?('loch the appropriate boa:
Type of Pryer(required):
in I am a employer with employees(full m4L'ur peN-Ilia)• 7, 0 New construction
nI am a sik pmiinmr prorputieethipmid have no empluyms working for me in II. tr lemodeling
an!,o"apanty.INn weettert'COW.ilb wane mound l
9. 0 Demolition
10 I am a hornet imardoivaall week myself.f No workers'comp_insurance cryuiteLl t
401.1.1..lit, u � conductncemsd win he micxs to conduct all work CM mproperlyproperlyI will 10❑Building addition
emus:than all euremeton either haw workers'curopcmati n insurance or are wilt 1 la Electrical repairs or additions
ianetui with nu employees.
12.13 Ph/robing repairs or additions
5 I m a gcsieral contractor and I have hind the sub-contractors lasted on the mulled attest_ 13 Q Roof repairs
Thews sob-contractors hair employees and lure waa1kcrs'rump.insurance_:
DOther
6.0 WC are a cugn ration and it9 otfbim have e n xahXd then nghi of etenipou l per ArKiL c. 1 . --------.—_.
152.(1(4).and we have no om4aloy ecs.[Nu workers'comp.insurance required.)
)
*Any applicant diii checks boa al mush also fill out the section below showing Their workars'compensation policy infunnativa_
t Homeowners who submit this affidavit indicating they are Ak ing all work and then hire mould contracture must submit a newt all iimil indicating such.
leomtra iurui that check this box mug attached an additional sheet showing the name of the smlrct ntr ucttiu and state whether ma nut these amities hate
anployee. If the sub-contractors lute ampluye,cs,they mind pmtide 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 CW(AC..i's. L K INt t COS\A it tin r.S yr i.et'_, —
Policy#or Self=ins.Lie.#: - ?-5U e)— ' K 6(03 —s.1—/l Expiration Date: 1\-3 a-Z 1
lob Site Address: Z Y1 (.1.:`,A c.s a- City/State/Zip: FGre ee . ( Ul Di:, Z
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 e. 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify tender the pains and penalties of perjury that the laferti aaoa provided above is true and correct
Si nature: Gf ------- Date: —2.`k—Z Z-i
Phone It: '-\\- rc— C1..i;1 Official use only. Do not write in this area.to be completed by city or town o i official II
City or Town: Perntitll.icense#
Issuing Authority(circle one):
I.Board of Ilealth 2.Building Department 3.('ity:ffoan Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
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s SAC
Massachusetts '�'4" '<<
X DEPARTMENT OF BUILDING INSPECTIONS
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+w' l`. r" 212 Main Street • Municipal Building v4, r
��r«TAr
Northampton, MA 01060 fbj Bj�'�0c
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born (insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the
Massachusetts State Building Code, codified di;780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title. \ /
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s)who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license,and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel,I acknowledge.that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of ,20 .
(Signature)
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