06-023 (2) 56 LEONARD ST BP-2017-0603
GIS#: COMMONWEALTH OF MASSACHUSETTS
MamBlock:06-023 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2017-0603
Project# JS-2017-000973
Est. Cost: $2000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
cont.Class: Contractor: License:
Use Groin JDR BUILDERS 074104
Lot Size(so. ft.): 40815.72 Owner: RYAN JAMES M&BRENDA M
Zoning: URA(100)t Applicant: JDR BUILDERS
AT: 56 LEONARD ST
Applicant Address: Phone: Insurance:
Y O BOX 4 (413)665-7587 WC
NORTH HATFIELDMA01066 ISSUED ON:108112016 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF - 11 sq
POST THIS CARD SO IT 1S VISIBLE FROM THE STREET
Inspector of Plumbing Inspector f Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House ft 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 10731120160:00:00 $40.00
212 Main Street,Phone(4t3)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
-- City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
OCT ' 8 212 Main Street Sewer/Septic Availability _.
Room 100 Water/Wen Availability
ail ------ - Northampton, MA 01060 Two Sets of Structural Plans
"-----------phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,// RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING A
SECTION 1 -SITE INFORMATION y /7- GO j
1.1 Property Address: This section to be completed by office
S(0 L"ypw,-44^'t� c Map Lot Unit
Zone Overlay District
L4 Vis, -144"
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1
2.1 Owner of Record:
o• rA r. - L.P17y -A ` •rfs 11i1� OG33
Name riot) Current Mailing Ad cess:
m
( //1) i-{1Z - ti5's_
,h2t �--- TelepncTelephoneSignatu —
2.,2 Authorized Agent: -p
Jog. got- ca 5 /A . t� ZoN< L/ ,vc. li..4'? t > X11/1 .
Name(Print) Current Mating Address: CNC (,t.
/F 37�(- 7yB3
Signature �+ Telephone
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 (b)Estimated Total Cosi of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection `
6. Total=(1 +2+3+4+5) � L- Check Number e/7''/✓
This Section For Official Use Only
Building Permit Number. DateIssued'ed
Signature: er- r' "'
IMINor
Budding Commussionertinspector of Buikengs Date
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 ht ed in by
Building Dup. • cm
Lot Size r
Frontse
.t
Setbacks Front
ide L: R: L: R:
Rear
Building Height
Bldg.
Square Footage "; 111MoenpenSpace Footage
(Lor ama minus bldg&paved
M of Parking Spaces
Fill: IOWA ........... _,
(vutwne 3 Locationl
A. Has a Special Perm' /Variance/Finding .ver been issued for/on the site?
NO O DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was thz permit recorded at the Registry o reeds?
NO O DONT KNOW O YES O
IF YES: er.er Book Page and/or Document S
B. Does the s' e contain a brook, body of water or wetlands? r O DONT KNOW V YES O
IF YES has a permit been or need to be obtained from the C•,servation Commission?
Need. to be obtained O Obtained O , •ate Issued:
C. Do a signs exist on the property? YES O NO O
IF ES, describe size, type and location:
D. Are here any proposed changes to or additions of signs intended for the propert ? YES O NO O
IF ES, describe size, type and location:
E. Will e construction activity disturb(clearing,grading excavation,`� or tilling)over 1 acre oris it part of a common plan
that 'I .isturb over 1 acre? YES O NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) I I Roofing
Or
Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs Int Decks I❑ Siding(❑J Other(Cy
Brief Description of Propos �p 1I�-�r g 'e �
j
Work: I 'p/�/ ..._
Alteration of existing bedroom Yes _No Adding new bedroom lyes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roli -Sheet
Sa,If New house and or ,dell • • . existin• 1.ousin• corn•lete the f t Ilowin•;
a. Use of building:One Family _ • 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 We..• •ves Number of each
g. Energy Conservation Compliance. Masscheck Energy Comp .roe form attached?
h. Type of construction
I, Is construction within 100 •f wetlands? Yes No. Is construction within 100 yr. floodp -'n Yes No
j. Depth of basement or •afar floor below finished grade
k, Will building confo, 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, RifiRts,( 6_ t"A - 1)- - .- ,es Owner of the subject
properly `
hereby authorize S J V R y" i`J)s s fri l
to t on my behalf, in all matters relative to work authorized by this building permit application.
171 ill 0 Io -�_y 1tc
Slgnature of Owner Date
S S ,as OwnertAuthorized
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 and penalties of perjury.
7) sea s5
Pdnt Name
Signature er/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su^�per'vSupervisor: ��J` Not Applicable ❑
Name of License Holder: J, ) j-Jai,.$ 6 7i/or
License Number
�o 7 .vo. srii�i�-,r� m4 oro c `��� 1 5S
Address Expiration Date
DI 3 -7 - 7 � g
Sign Telephone
9.Registered Home lmprovament Contractor: Not Applicable ❑
X, fe- B04-4 c;), i ,,,C 18.
tf 7S 3
Company Name Registration Number
c-c2.7
GG icy —t�
Address ) / /�., e y/y'� Expiration Dale
f"Va" (7 • 'M /9 " �� / 5 ...-Telephone ` " 76Y
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 buil - g permit.
Signed Affidavit Attached Yes No 0
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. Math Edition Section 108.3,5,1.
Definition of Homeowner:Person(s)who own a parcel of and 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 buildine 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,Slate and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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: ¶a Fcnvr,.rr{ Si- , to S 010- 0ICS3
The debris will be transported by:: / L DU�t-5
The debris will be received by: ' 17Ch /C€ c t
Building permit number: / U
Name of Permit Applicant
7
Date Signa re of Permit Applicant
The Commonwealth of Massachusetts
,A Department ofIndustrial Accidents
h
Office of Investigations
1 Congress Street, Suite 100
Y� Boston, MA 02114-2017
V �
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Bviticc�LJ Htj
_
Address: 10%-
City/State/Zip:
x
City/State/Zip: A/Qt /F the r .a'0(16Phone#: 37Y- A 3
Are you an employer?Checl he appropriate box: Type of project(required):
19/1 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
listed on the attached sheet. 7. 0 Remodeling
2.❑ tam a sole proprietor or partner-
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.I
required.] 5. ❑ We are a corporation and its l0.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
Y P 12. Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy information.
t 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 name 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 for my employees. Below is the policy and job site
information.
Insurance Company Name: Se /ec.f/� �t
l'✓e Ins- 9-11
Policy#or Self-ins. Lic. #::G w ` 9'0(#2U t/'7 7 Expiration Date: /)
Job Site Address: .-5-62 k ' 1tK 91- - City/State/Zip:LET.-bS,
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 S250.00 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 verification.
I do hereby certi nder th pa' s and penalties of perjury that the information provided above is true and correct.
Signature: L Date:
'7 /
Phone#: .� / `l -7 9p-
Official use nly. 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#: