35-153 (3) BP-2022-0738
788 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-153-001 CITY OF NORTHAMPTON
Permit: Acc Structure
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0738 PERMISSION IS HEREBY GRANTED TO:
Project# shed Contractor: License:
Est. Cost: 7000
Const.Class: Exp.Date:
Use Group: Owner: M MONSKA JOHN M&JEAN
Lot Size (sq.ft.)
Zoning: WSP Applicant: M MONSKA JOHN M &JEAN
Applicant Address Phone: Insurance:
788 RYAN RD
FLORENCE, MA 01062
ISSUED ON:06/23/2022
TO PERFORM THE FOLLOWING WORK:
SHED
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I I .)2
Fees Paid: $30.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts `�. v ' -1-IR
Board of Building Regulations and Stands ds J `� PALITY
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Massachusetts State Building Code,780 RUN 2 1 E
Building Permit Application To Construct, Repair;Re r. Or Demolish evis Mar 2011
One-or Two-Family Dwelling`n o°Faum,n,
This Sec ' n For Official Use Only--'---Q o?M CT1ON
Ofps� S
Buildin Permit Number: s A)- �- 7.3 Date Applied: _,.
Kei rn.) 4Z5 IZ 613 Z!}ZZ
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
."7Yf IZyr• 1R-oc c) Pic)fzewc. roll 35 !53
1.1 a 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(It)
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 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
e \n n PIO ns1Cr\ Ftuc \'1 Pi 01 o G .-
Name(Print) City, State,ZIP
"7? 12-yrk r —moo c n Li 11-S-G3-S-sa 1 'a v. r,ny 0 r\N'"7.,W 9 r►a cd ,Ce,
No. and Street Telephone Email Addr ss
SECTION 3: DESCRIPTION OF PROPOSED WORK2(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.fir Number of Units Other 0 Specify:
Brief Description of Proposed Work': e.,c-e—c.,T A 1 L X'..c) S 41 D
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1.70-a U 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) •
t G Total All F s $
Check No.' Check Amount: Cash Amount:
6. Total Project Cost: $ "1 O- rC) 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
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 0 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
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: OWNER1 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.
SoV\ � lO /\ l(0 r/a ) av3a
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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
6 HO S*.
FRONT SETBACK
FRONTAGE
City of Northampton
,°jr�r Sys .. sic
Massachusetts �o,'' _ ; .
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s ' DEPARTMENT OF BUILDING INSPECTIONS ;>, 0 `��, ',. 212 Main Street • Municipal Building yJti, �
Northampton, MA 01060 jsy ;•-. e'
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: VA ( I e y I c..yC 1 i N e
s.)
The debris will be transported by:
Name of Hauler:
i nature of Applicant: Date: '2l GUZ U
—` The Commonwealth of 1 assachirsetts
nil , Department ofIndustrial_Accirlents
l = 1_= 1 Congress Street, Sulk'100
=m.=; Boston,M4 0.2114-2017
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fit_inrkers' Campensa don Insurance. f!idaeit:Builders.;Contractors'Electricians'Plumber:.
TO BE FILED WITH THE PEILMFITLATGALTEHORITY.
Applicant Information Please Ptint Legibly
Name ( ess'Org tionanditi 1): ----3-0 v, n No n S i e...cam
Address: rl T2-.) r , Z.o 7)
City/StateiZip: FI 6`-e.nr a. rnfl 0 (c)c,2 Phone#:L{ 13- - -3- 5-s-a I
Are you se employer!Check Ike appropriate Lox: Type of project(required):
:.Ej I ars a eaaployw IA& amplorees(full and c:at:rti=o).+' 7_ El New con n-action
2..❑I am a sets propnator to psataxuip and lave no amploq.a: zor+,:ina Ear ma in 8111 Reanixtekti.
izy:rpaclty.(No vtce ors'cccp.:asusaac. recr it d]
9
Li Kam a bc_ao no�rdoing all stark myself.[No worker:*comp.insurance regnirnd.]' ❑ IltloII
10 0 Building addition
i.E I sr=a her_aoaner and uillba hiring co scion to conduct an weak on my pcaperty. I will
crosue that all contractors either have workers`compensation invoraace cc are sole 11.E Elect ical repairs or additions
Faliriatoc:with no eeplcysos.
12.0 Pt` thirty repairs or additions
`.❑I am a men:.contra:taraad Ihave h_mi.the su.t-ccasaco:r.1i:tad on th.o atrachul execs. 13.❑ f repairs
These sub-comm.:Dors harm smpLoyee:and h.a_•a w: i:-'cDr.p.Matuanc..t
6.0 W.are a corporation amd officer:
its ocer:'sirs exercised their rig:::cf exemptions par RdGL c. D Other
cat
252, s 1(4),and wo hasro no eeaploye.i.[No workers'comp. uance rcgtrirsa l
'Airy applicant that chic;.:hoe 1 must also fill out tfsa section boLow sh wiva-hair workers'conapeasanun policy information.
t'Homeowners who submit this affidavit iaaiicar-•c Lan a o deans all work and than hire o tsido r antactcs.must s`obmit a navy afidaa:::indica:iac such.
rCcntractors ttai chock this box must attached as addition/sheet shoeing the name of the cub-ccatractors and state whether cr nos fnose aotties no
employees If the sub•centractan have employee:,key must pronto their workers'comp.policy number.
l arm an employer that isproviding workers'compensation insurance for tots'employees Below is the polies.anti job sire
information.
Insurance Company N'rn :
Policy 4 or Self-iris.Lic. _: END117413011 Date:
Job Site Addte's: Crt 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 tinder MGL c. 152,125A 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 fonn of a STOP WORK ORDER and a fine of up to S250.00 a
day against the v tolator.A copy of this.statement may be forwarded to the Office oflnvtestieatios of the DLA for insurance
coverage verification.
I do Thereby cerriA under the aims and penalties ofpeh,hehy that the information provided above is ante and correct
Sitmatiire: al / Date: / `3 J d2
Pbon,e4: LI )3 -��63— S 3 I
Official use only. Do not t+a ate in this area,to be completed by city ar roten official
City or Town: Pertnit,'Iicen.e#
I>aung3uthoriry ircle one::
1.Bt}aril of Health :, Building Department 3.City'Town Clerk 4.Electrical Inspector :, Plumb:ae Ia:pertor
6,Other
Contact Person: Phone 4:
City of Northampton
7O- TO \S.. i. S/
0 ` Massachusetts <i5 ,te
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", ��• . DEPARTMENT OF BUILDING INSPECTIONS y; j F �,
% 212 Main Street • Municipal Building Jb a�
\ _a� Northampton, MA 01060 SI%h;- ;:j\ C
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, -"--3---0 V\ N rvid As K.0, (insertfull legal name), born o3//��/ / 9 7(g ) (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 at 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 d9' I day of —10 r''Q- , 20 a 4-
(Signature)