31A-126 City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work:
The debris will be transported by: �e-s `�ri,�G�i►tiG,
The debris will be received by:
Building permit number:
Name of Permit Applicant -
/ d z- ,G
Date Signature of Permit Applicant
I �i�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
,M www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( Please Print Legibly
Name (Business/Organization/Individual): A4an �,epi� ' -otcx
Address: qLq <F&13X IRA
City/State/Zip: ft, QW-2 Z Phone#: i 3
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
I am a sole proprietor or partner- listed on the attached sheet. 7.18 Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
iformation.
tsurance Company Name:
olicy#or Self-ins.Lic.#: Expiration Date:
)b Site Address: City/State/Zip:
Mach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification.
do hereby certify nder the pains and penaies of perjury that the information provided above is true and correct.
i atur : Date:
hone# /
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 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: a rx
License Number
Add r Expiration D to
re Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company me Registration Number
41, 6/ / 01(3 Address Expiration Date
y11(tt l7v� tM Gc D<e)'?Z Telephonell3
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 10835.1.
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 1:1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[p] Other[C]
Brief Description of Proposed _
Work: V-iew%.ov 1 w(cc 091"Lt' 4 " 1 4T )L
X1r
Alteration�of existing bedroom Y s cam.�n No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing 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?
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
property
hereby authorize av`--
to act n behalf, al ers relativet6 work authorized by this building permit application.
D4 2�
Signature of Owner 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 pains and penalties of perjury.
Print N e
J
S Si
Oaqo of Owner/Age Date
Department use only
CEI City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
4-1 JAN Q 2016 212 Main Street Sewer/Septic Availability
{ Room 100 Water/Well Availability
L
OF$UILLWG INSPECTIONS orthampton, MA 01060 Two Sets of Structural Plans
ORTHAMPTON M 3-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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:
S4_ Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1
Nam Pri Current Mailing Address:
Telephone
Signature
2.2 Authorized Aaenf.
--').�c P06 5-'1 s�\�-AfSLQ"� yy'- Gcr
Name(Pr' Current Mailing Address:
/1" �- t413 zee' —lU
Sign ur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building ,.,�y`�ry (a)Building Permit Fee
2. Electrical Lam' (b) Estimated Total Cost of
z/ Construction from 6
3. Plumbing �/ -� Building Permit Fee
4. Mechanical HVAC
5. Fire Protection
6. Total=0 +2+3+4+5) 6 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2016-0911
APPLICANT/CONTACT PERSON RYAN REGAN-LADD
ADDRESS/PHONE P O BOX 59 SHUTESBURY01072-0059(413)259-1149
PROPERTY LOCATION 6 JEWETT ST
MAP 3 1 A PARCEL 126 001 ZONE URB000)/
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: REMODEL KITCHEN ADD 1 ST FLR BATH&INSTALL REPLACEMENT
DOORS/WINDOWS
New Construction
Non Structural interior renovations G
Addition to Existing,
Accessory Structure
Building Plans Included•
Owner/Statement or License 060508
3 sets of Plans/Plot Plan cT&H(C
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOTION PRESENTED:
4-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 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
Demolit' lay
Signa e of uilding Of 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.
6 JEWETT ST BP-2016-0911
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A- 126 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-0911
Project# JS-2016-001547
Est. Cost: $92000.00
Fee: $598.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RYAN REGAN-LADD 060508
Lot Sizes . ft. : 8058.60 Owner: COHEN BATYA&NICOLE HAMER
Zoning URB(100)/ Applicant: RYAN REGAN-LADD
AT. 6 JEWETT ST
Applicant Address: Phone: Insurance:
P O BOX 59 (413)259-1149
SHUTESBURYMA01072-0059ISSUED ON:1/1 9/2 01 6 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN, ADD 1 ST FLR BATH &
INSTALL REPLACEMENT DOORS/WINDOWS - LVL Calcs required
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 Sillnature•
FeeType: Date Paid: Amount:
Building 1/19/2016 0:00:00 $598.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner