28-021 (7) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 1M IJ, S S -7 Y/
License Number
Jo- f-I-� M A 1 q-
Addr s Expiration Date
-71
Sig ure Telephone
9. Registered Home Im rovement Contractor: Not Applicable ❑
Comoanv Name Registration Number
Address Expiration Date
Telephone
7�1r3
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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of 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.
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.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
Ad"Om
Y�
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) 62`3 X
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors i]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[❑] Other[a
Brief DescriQtion 9f Proposed ) GI f SO V'a's" ..t�
Work: td,o >,A) t2M tiYL' hedcuj.A `� ;:✓t^ �tS� �00& 4 . '
Alteration of existing bedroom Yes No Adding new bedroom _Yes No f +F
Attached Narrative � Renovating unfini he basement Yes �No
Plans Attached Roll -Sheet �' u6 cs �; ey )p q rc. S�C 14 W S
sa. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family_ _ Two Family Other SIC(f
b. Number of rooms in each family unit: Number of Bathrooms 1
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
"l ,
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, e,glV�4�'t` 14 as Owner of the subject
property
hereby authorize � VS
to act on m ?half, in all matters r tive t ork authorized by this building permit application.
Signatur er 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 pai d penalties of perjury.
Print Nam
Signatuik Owner/Agent Date
IV
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 in by
Building Department
Lot Size
Frontage q '�Ll
Setbacks Front 57
Side L: Yk R: 2- L: R:
Rear S
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES Q
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
W-MVE 212 Main Street Sewer/Septic Availability
T h i Room 100 WateNWell Availability
2 ', orthampton, MA 01060 Two Sets of Structural Plans
hon 41 -587-1240 Fax 413-587-1272 Plot/Site Plans
Electric, Piu�-,Li,,y&Gas inspeotlons Other Specify
Northampton,WA 01060
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
cc"A"C-e Map Lot Unit
(',c)o P-yA AJ
Zone Overlay District
IFL,>1Lr,vC4, 'A lll--- U/D(d� Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
11A1
Name Pri / ? Current M ilin dd ess:
Telephone
Signatu
2.2 Authorized Agent:
S 12, E Lt
Name(P' t) Current Mailing Address:
Signatuk Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0,VA) (a) Building Permit Fee
2. Electrical ,�;IOU (b) Estimated Total Cost of
Construction from 6
3. Plumbing 3 00(2 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2+3+4+5) 000 Check Number J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0267
APPLICANT/CONTACT PERSON JDR BUILDERS
ADDRESS/PHONE P O BOX 4 NORTH HATFIELD01066(413)665-7587
PROPERTY LOCATION 690 RYAN RD
MAP 28 PARCEL 021 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 23 X 27 LIVING/DINING BEDROOM UTILITY,LAUNDRY RM,22 X 22
ATT GARAGE REBUILD DECK& SIDING,ROOF&WINDOWS
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included:
Owner/Statement or License 074105 �C �CI�/VlC
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
proved 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 UNDER: §
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
De ti
ure of uild' icial Date
Note: Issuance of a Zoning permit does not relieve a applicant's 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.
690 RYAN RD BP-2'016-0267
GIS#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 28-021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2016-0267
Project# JS-2016-000411
Est. Cost: $98000.00
Fee: $573.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JDR BUILDERS 074105
Lot Size(sq.ft.): 36633.96 Owner: PURSEGLOVE CANDECE
Zoning: Applicant: JDR BUILDERS
AT. 690 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 4 (413) 665-7587 WC
NORTH HATFIELDMA01066 ISSUED ON:912312015 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT 23 X 27
LIVING/DINING,BEDROOM,UTILITY,LAUNDRY RM, 22 X 22 ATT GARAGE, REBUILD DECK &
SIDING,ROOF &WINDOWS
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 9/23/2015 0:00:00 $573.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner