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29-152 (11) 519 RYAN RD BP-2016-1135 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29- 152 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-2016-1135 Proiect# JS-2016-001946 Est. Cost: $9500.00 Fee: $64.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL MCCUTCHEON 062544 Lot Size(sq. ft.): 959191.20 Owner: NORTHAMPTON REVOLVER CLUB Zoning: Applicant: PAUL MCCUTCHEON AT. 519 RYAN RD Applicant Address: Phone: Insurance: 134 EASTHAMPTON RD (413) 584-3352 O WESTHAMPTONMA01027 ISSUED ON:4/11/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 8 X 40 SHOOTING STRUCTURE 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 Sitnature: FeeType: Date Paid: Amount: Building 4/11/2016 0:00:00 $64.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File 4 BP-2016-1135 �0 N IQ fA- APPLICANT/CONTACT PERSON PAUL MCCUTCHEON ADDRESS/PHONE 134 EASTHAMPTON RD WESTHAMPTON01027(413)584-3352 PROPERTY LOCATION 519 RYAN RD MAP 29 PARCEL 152 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid %1,wo af Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 8 X 40 SHOOTING STRUCTURE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildinp,Plans Included: Owner/Statement or License 062544 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 9RMATION 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 Demolition Delay S ure of B uihimrOffifcial 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. qL Versionl.7 Commercial Building Permit May 15,2000 R " Department use only Ity f Northampton Status of Permit: uil ng Department Curb Cut/Driveway Permit LIAR 2 S 21 Main Street Sewer/Septic Availability ' oom 100 Water/W611 Availability r Northanhpton, MA 01060 Two Sets of Structural Plans - phone 413-587-1240 Fax 413-587-1272 Plot/Site Pians Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office w -l ve" .. '"�"� Map Lot Unit 'n P Zone Overlay District __ _....... _..__.. Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: 44 OkO61 ' Signature Telephone 2.2 Authorized Agent: f Name Print Current Mailin Address Signature Telephone Lq SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical rn` (b) Estimated Total Cost of Construction from 6 __. 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+ 5) Check Number This Section For Official Use Only Building Permit Number =Date ued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE t Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description I`;Enter a brief description here. A Q j Of Proposed Work:., �SA' SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A AssemblyA-1 ❑ A-2 ElA-3 ❑ 1A El ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility E-1Specify: _ .......... _.._. ... ..... M Mixed Use ❑ Specify: S Special Use Specify v COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE ... ._ .._ Existing Use Group: ...... Proposed Use Group: .__ . Existing Hazard Index 780 CMR 34):i. Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) i 1st st _..: nd 2nd - 2 ..... ....... ................. .......__.........._........._.......... .._.._..... ... 3rd 3rd : _,... ._.. _,_r.._ ._... _...,_ _,__...._ _.... .., 4th 4th ..................._.._.._.............__........................._............._..................._........._..: Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) f i ' Total Height ft �.\... ....... 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑ I i Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 'O <14CZ Frontage �'� } Setbacks Front Side L: R:>:` L: R 1_ Rear . Building Height Bldg. Square Footage } % =—y .Lr 1 � .� f.. Open Space Footage % (Lot area minus bldg&paved r t R' parking) #of Panting Spaces Fill: (volume&Location) d ,,, .:.:. . A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? ........... --------- . Needs to be obtained ObtainedQ , Date Issued _... C. Do any signs exist on the property? YES , NO IF YES, describe size, type and location: F=nom D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO t IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, exc vation, 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. r Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): _. Name Area of Responsibtlity Address Registration Number Signature Telephone Expiration Date __.. ... .._....._...... _......... . . ............. _ ...._... ._. .. Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ._.... ........ . Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date _._..... ..__._...... ..._..__.. __.. ._..._...... ........... Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor / JJ j, t CADD Not Applicable ❑ Company Name Responsible In Charge of Construction ...... , Address Signature Telephone i II Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No Q SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT - - - -- - as Owner of the subject property hereby authorize I Q .._. , �` to act on my behalf, in L matters relative to work authorized by this building permit application. 71 Signature of6 wner 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_ pains and penalties.of perjury. ...... - _ Print Name n S Signature of Owne/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction u ervisor: Not Applicable ❑ Name of License Holder _.1. �.__ ... .._..yam `. ... C�^.. __.' 7 License Number Address Expiration Date Signature Telepho e SECTION 13-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 The Commonwealth of lllassachusetts 4, Department of Industrial accidents Office of Investigations 600 Washington Street .Boston, MA 02111 _ www.rnass.govldia Workers' Compensation Insurance Affidavit: l uilders/Contractors/Electricians/Plumbers Applicant Information Please Print Leffibly Name(Business/Organization/Individual): U _ Address:-! 39 City/State/Zip: Phone#: y r Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2. m a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling V�aSTZip and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, employees and have workers' Building addition [No workers' comp.insurance comp. insurance. required.] 5. 7 We are a corporation and its 10.❑Electrical repairs or additions D.❑ I m 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.❑ 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. +Contractors that check this box must attached an additional sheet showing the nam of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/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 under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifcation. I do.hereby certify i4er the poi and penalt' s of perjure that the information provided above is tr a and orrect. Siznature: Ali' Date: Phone#: J -3-3, Official use only. Do not write in this area, to be completed by cioJ or town official City or Town: Permit/License# i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.EIectrical Inspector 5.PIumbing Inspector b.Other Contact Person: Phone#: i -Zoo tso 40 0 INS; Q\ o 0 29- l Sz o - " _ -- -- RAN 4 ec 4 Z a^ had '9 4 iso t n — � M LjOF o o ? t Ma L• ems �0 RGE .r n � H 7 � 4 ro 29-16Li 69 60 Al 31 �s / F� �T E7 OF GEO L 35214 `SSIONAL \C.�A -7r r OF If 0 E i i. .35214 AL E �'f,�(� o lb „ , Z rT rp .! r `'J `T ' 17 Y' e � r OF 8E0 14 f f- t i i' t 00 aay t� M { _ 1/Z OF GEORG 5214