35-157 (10) 824 RYAN RD BP-2017-0914
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35 - 157 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catetiorv: INSULATION BUILDING PERMIT
Permit BP-2017-0914
Project!i JS-2017-001562
Est. Cost: S4413.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Cons.Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 106062
lot Size(sq.ft.): 47044.80 Owner: APOLINARIO JILL
7oninc: Applicant: URBAN & SONS INSULATION CO INC
AT: 824 RYAN RD
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:2/6/20170:00:00
TO PERFORM THE FOLLOWING WORK:ADD 12" CELLULOSE INSULATION TO ATTIC
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 2/620170:00:00 S65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0914
APPLICANT/CONTACT PERSON URBAN &SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 824 RYAN RD
MAP 35 PARCEL 157 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT \
Fee Paid ]� / 7.7
Building Permit Filled out �['(J )
Fee Paid _
TvoeofConstruction: ADD 12' OSE INSULATION TO ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106062
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
roved _ 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 Be 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
._ Dem. ' -on u-la
Signat - . Building Official 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.
/�% �.` City of Northampton r Y ic $ ;Tager g �-
,- ,Let Building Department o Yo 'P^ `� M :--Ai;
c.,;)
212 Main Street "1>+rj't(' �: s""��}�t-'i -._�- a. t, f.
\` , 0 Room 100 °6f .4 i4-.9.- `1�t*a .�.�
Northampton, MA 01060w'1�� u r'ra -V^-* :
phone 413-587-1240 Fax 413-587-1272 t0A ,i r1i'rgi ,i "- ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address- This section to be completed by office
. -,...\
� \4. 1 i- 13‘
- \_ \‘ \ 0 Map Lot Unit
1'� C< Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
E.1 Owner of Record:t
Name(Pring Current Mailing Address;
Telephone
Signature !✓mfli l:
2.2 Authorized APeot:---€.\\
V( ' '7.c.-,s \ (tft {, l_ e
Name(Print) ._� Current Mailing Address
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 Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �(/
�3 `�(�J
R. Total = (1 +2+ 3+q+5) 11-/ 11-1 3 ' Check Number -71915
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
Budding Department
Lot Size
Frontage ._ .._ __ _........_
Setbacks Front I 1
Side LC.1111
Rear
Building Height r'--- I LI I 1
Bldg.Square Footage I– -- io ...1 --- -- ---
Open Space Footage %
(Lotarenminusbldg&roved C J L IC��i r j I
parking)
#of Parking Spaces L. !-' -11
Fi(L ..._i1
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW Chi YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW ® YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued: ( __
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. MI the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part of a common plan
that will disturb 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 ri Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding 117) OthegiS a
Brief Description of Proposed \' - �r`\ Vi\ S„'a /1/NAS t.0 H It C V—
Work'. \\ T'� �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll - Sheet
$a.If New house ander addition to'existinSt hour nchigomplete':the following:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: ,_, Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating?^ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j, Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? tN4C, Yes No .
I Septic Tank_ City Sewer- Private well City water Supply
SECTION 7a.OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _ , as Owner of the subject
properly (� 1,� e-p
hereby authorize JS-.,a?�`J NS�\�1 ,V q+
to act on my behalf,in all matters relative to work authorized by this building permit application.
...
Signature of Owner Date
1111.1111111M11.11
++wner \ 1 �\\`'y1
i, \ 6A)Z\t\ Y civ ` i ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief,
Signed under the s
pains d penaitie of perjury.
�o cc
Print Name
Signature of OwnerfAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:r,✓' Not Applicable 0
Name of License Holder. o + 'N1
� ,
� ls- .����.s.,r✓—~.r
License Number
3B \- \Q'L.' t/ ST ,SEZ b
Address aS Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor r? 2 r Not Applicable ❑
Company Name egistration Number
Q f<-y s-C � - \Ct tx
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15$§.25C(6))
Workers Compensation Insurance affidavit must he 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 X No ❑
n. - H'omc OwnenExemption
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 198.3.$.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 el)such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand 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 nut resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perforin work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with tie State Building Code,City of
Northampton Ordinances,State 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: cl<'L* -NNA
The debris will be transported by: \�cC--6==-!J
The debris will be received by: 2 SE \G
Building permit number:
Name of Permit Applicant \ Y \-\.\\1!
\ -\CA- 'i
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
--v---
ran,
of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
' Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
► _
v
Name (Business/Organization/Individual): C+! \��,�^�`� �k} V
Address:: tS \\STr.,,(C 7-' 5 ( S {^' C-n
City/State/Zip: Phone#: 3°)--- ---..,_
Are you an employer? Check the appropriate box: Type of project(required):
IN I am a employer with Sit 4. p I am a general contractor and 1
employees(MI and/or part-time).* have hired the sub-contractors 6. New construction
2.n I am a sole proprietor or partner- listed on the attached sheet 7. ri Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
9Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. L[ We are a corporation and its 1o.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
.coo workers'
myself.m seright of exemption per MGL
Y NoP 12.F1 Roof repairs
insurance required.] t c. 152, §i(4),and we have no s \ ,. n`
employees. [No workers' 13. Other CI ` 1.
comp.insurance required]
*Any applicant that checks box kl 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: \ L-. Ca.`
Policy it or Self-ins.Lic.#:NIN!4 '''�''��_[��SCSg107,..>.i5� t
`I ," i xpiration D :\ -" \
Date: 1���
Job Site Address: �l�^ �1 5J illCity/State/Zip:Xf L t-p \et- t'.Q .,-'�
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 andtor 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 he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the ^ii allies ofperjur, that the information provided above is true and correct.
Si¢namre: �>v .' lcDete:
- \1 -\
Phone#: -1 '.. — ------f)0- -'
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):
- I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone in__
RISE60 Shawmut Road,Unit 21 Canton,MA 020211339-502-6335
ENGINEERING www.RJSEengineering.com
OWNER AUTHORIZATION FORM
(Owners Name)
owner of the property located at:
82>i g (0_16 ic,rD
(Property Address) _—— •
FLY- -tti MA ,
(Property Address) i �'
C
hereby authorize v (Z rt J�\y 't,r n
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners-
responsibility to close out this permit by contacting their municipality at the completion of this work.
/_ 1
Owner's Signature
7
Date
62016
c0-�-•.'rte
Properly 1_* \'
contractor � .�v�iY(�
Name:
Address: ---Yzzc cji 1�\(' � y ,S -
caw. state: �� .C)\\t
Phone:
Name: ty tTvner
_ - _ Addres _- ` ��- --
i 1
vf-N-\l\\)/� (contractor)attest and affirm that the building I intend
to insulate does not have any dpen air(knob and tube)wiling in the spaces to be'insulated and
that I have provided the property owner with a copy of this affidavit
Contractor signahae\ \\y
Data.