38A-041 (5) 18 LAUREL ST BP-2017-0712
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-041 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2017-0712
Project# JS-2017-001175
Est.Cost: $28600.00
Fee:$186.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: RYAN REGAN-LADD 060508
Lot Size(sq.ft.): 5009.40 Owner: WEENE BARBARA J
Zoning: URB(100)/ Applicant: RYAN REGAN-LADD
AT: 18 LAUREL ST
Applicant Address: Phone: Insurance:
P O BOX 59 (413) 259-1149
SH UTESBURYMA01072-0059ISSUED ON:1 1/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:POST FLOOD RESTORATION - KITCHEN
CABINETS, ELECTRICAL, INSULATION & DRYWALL
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 11/22/2016 0:00:00 $186.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0712
APPLICANT/CONTACT PERSON RYAN REGAN-LADD
ADDRESS/PHONE P O BOX 59 SHUTESBURY (413)259-1149
PROPERTY LOCATION 18 LAUREL ST
MAP 38A PARCEL 041 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Bee Paid
Building Permit Filled out
Fee Paid
TvpeofConstruction: POST FLOOD REST -KITCHEN CABINETS,ELECTRICAL, INSULATION
&DRYWALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 060508
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
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
Demob Del.
ature o Built ing a 'inial 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.
-- 41041
Department use only
-----7' I City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
I. 212 Main Street Sewer/Septic Availability
N
I• N ) Room 100 Water/Well Availability
i )_` Northampton, MA 01060 Two Sets of Structural Plans
I A phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
L--_______ Other Specify
AT N 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:
4& I 1 SAMap Lot Unit
\fir 4"• a 40—t .1.4=1"
'Id Zone Overlay District
� Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 s_.ar erot 'ecord: �/ •
(' J 1L4 �!� /7 ,.7wtce/ 5 , M.-f-7740,7741/4(l otia
N e �., ) Current Mailing Address: 6 Ycp
(2/2/6-1("2 — 06-7/G Telephone
V Si. ature
2.2 Authorized Agentt�:JJ /� )
,'P�xilon Cf�-ezn- -a- 1 Porn . ;"J- 16,4444-16.7a-u-r-ri Ma. et 67
Name{P�rh) Current Mailing Address: l
44.
rAs.Gr / _ Carr �C/ `iiia z9—i@
S' ai Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (rut
Building Permit Fee
2. Electrical , 31S<_570 (b)Estimated Total Cost of
Construction from (6)
3. Plumbing / '730Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 41/Y6�r
6. Total=(1 +2+3+4+5) 2S (o p/) �" Check Number 3v9 4/OY6
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side I.: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(kat area minus bldg&paved
parking, ^,
#of Parking Spaces
Fill:
(volume&Location) „—
A.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
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 Q DONT KNOW O YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 QNO Q
W YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: -� Not Applicable 0
Name of License bolder- U1 P Neff n— � <. 'r� .._ _._ 5 CS,,p t
[7 fLicense Number
a • 46. 1 A,u; Sf b i /2 /i2 //b
Address Expiration Date
3ipri,se Telephone
,f/(7A-11' au y.3 25-9—/vi/li
-• acau= im• • ;p.-ntCont =.nr: Not Applicable El
Company me, UVJ Registration Number
/2 L.
Address ( p q f 3 259JL'tly Expiration Date
91,41 P�(itt P �I 013 L J ) iQ Telephone iatlfifil
G[G"r7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 )8. No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 28833.1.
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 he,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 persons)
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 n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [E] Siding[D] Other[I7]
Description of(propos t4C-i{w Ca.(v.,„_ye
Brief Des
Work: Yb.Sf TIOC/a re iirki n 4rez-- — 0t.e1,-.L:<-.1 ref-a“-e4 -43su-:- (rid r/1-y-L.-ate
Alteration of existing bedroom Yes X No Adding new bedroom Yes OC No
Attached Narrative Renovating unfinished basement Yes X 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?
I 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
I, .4 0 .4 , , A ..a._39---- ,as Owner of the subject
pro.
hereby authorize
to a my be Galf, in all matters r (five a work authorized by this building permit application_
x / 2-4/)dL e" _E__
gnature of Owner Date / / L
I, I - Cv. 7./.yj2 , ( yyam..- C /C� /i"---tacii , as Owner/Authorized
Agert'her y declare t at t e tatements and information orYthe foregoing ap tion are true an ddd accurate,to the best of my knowledge
and belief.
Signedunderthe pains and penalties of perjury.
/via g lee)an- laces
Odra N ati. ✓/� `X_y'//� / /
Sig r o ner/Agent Date
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: /f Luck/5 ,/,
The debris will be transported by:
The debris will be received by: L' iZ-s
Building permit number:
Name of Permit Applicant "" 72,Ja,,-1 Doti/
4an v
112-7 c, 1)4Ce,- aII/
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
��_ Department of Industrial Accidents
I=1.
Office of Investigations
.a _/ 1 Congress Street,Suite 100
=j;�%% Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
Name (Business/Organization/Individual): �c0y-\ II —P. 6-A i\— —arJ4 _
Address: ' ,E ( (
AM 1 �C' RR .)5-9
( c-a.
City/State/Zip. � �e,5JOC'k Y�Q _ Phone ft: X1.3 2 GE- (6'6 _
Are you an employer?Check the appropriaiflox: Type of project(required):
❑ I am a employer with 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6. ❑ New construction
am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
s1hip and have no employees These sub-contractors have
8. ❑ Demolition
workingforme in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
1.❑ tam a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]f c. 152, §I(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
my applicant that checks box I/I must also fill our 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
tformation.
tsurance Company Name:
olicy#or Self-ins. Lic. #: Expiration Date:
rb Site Address: City/State/Zip:
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
allure 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 ofa 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
westigations of the DIA for insurance coverage verification.
do hereby certify u •er the pains and Staines of perjury that the information provided above is true and correct.
r
i: ature: 1i• .. ` ,_ 45 6 24 Dat-:
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#: