22D-029 (4) BP-2021-2336
158 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22D-029-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2336 PERMISSION IS HEREBY GRANTED TO:
Project# 1NS/ELEC UPDATES Contractor: License:
Est.Cost: 4000
Const.Class: Exp.Date:
Use Group: Owner: GIRARD JAY P
Lot Size (sq.ft.)
Zoning: WSP Applicant: GIRARD JAY P
Applicant Address Phone: Insurance:
P 0 BOX 60635
FLORENCE, MA
ISSUED ON:12/28/2021
TO PERFORM THE FOLLOWING WORK:
UPDATE WIRING, INSULATION
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.
Signature:
• t . 3)045/
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
if
1,1 T
''''''',,,,,6.:"*The- ommonwealth of Massachusetts
Boa "of B •lding Regulations and Standards FOR
kj.�� '490(7Mas chus tts State Building Code, 780 CMR MUNICIPALITYUSE
/,. 1; • Permit�Cpplic Lion To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
'? AI^•so� One- or Two-Family Dwelling
. ,;.(0�,'. This Section For Official Use Only
Building Permit Number f'' I~, 33 Ce Date Applied:
-A. .k ► 1 _ a►
Building Official(Print Name) Signature
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/sg , e- Rd.
1.1 a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/a/ ALI0-crt' /Pa-7
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publics Private 0 Zone.• — Outside Flood Zone? Municipal. On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
J P. &, rc e-a f''/C :^fir.c M.-1 0iO(&'
Name(Printl� 1 City,State,ZIP
/S8 12, 1 - /ac�'. y/3�y B SI `�a�-rd I , �� rwGi j iCc ✓ -
No.and Street / Telephone J J Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied$.. Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Desc iption of Proposed Work2: lZC,...�v.c P/c-s4sir 1 Op ct�,Q �/i ri"� /z�., c
a fJ j v � P-
'1 1I 4-41 o , i/p6-{� � -s
-'�r-"c � .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ O c, (, 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ..).) C G Q 0 Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees• " 5
Check No. TACheck Amoun Cash Amount:
6.Total Project Cost: $ L C'C tg 0 Paid in ...it 0 Outstanding Balance Due:
City of Northampton
e Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS '.
212 Main Street • Municipal Building
Northampton, MA 01060 3 ,�
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW/ private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: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
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained)n this applica is true and accurate to the best of my knowledge and understanding.
Print Oheor Authorized Agent's Name(Electronic Signatti
k' NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces __ Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE: 0.14`
REAR LOT DIMENSION:
REAR YARD I a°if
•
SIDE YARD ` SIDE YARD
FRONT SETBACK
FRONTAGE
•
City of Northampton
} Massachusetts '-
a
DEPARTMENT OF BUILDING INSPECTIONS 'le_ It
212 Main Street • Municipal Building a,
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility:
\TALL-ry CA. ► C
The debris will be transported by:
Name of Hauler: DVV N L-Tic
f\
1
Signature of Applicant: �' Date: /�193)?(
The Contnionwealth of Massachusetts
,. -' ' ,,
Depanment of Industritd Accidents
1 Congress Street,Suite 100
.c" S Boston,31A 02114-2017
, ,..„ ., ,
,/• www.mass.goWdio
SS others'Compensation Insurance Affidavit:BuildersiContrattortiElectritiansfPlumbers.
ft)hi f ILLD WITH THE PERMInriNG AUTHORITI.
Applicant Inforniation Please Print 1...egiblv
Name illasinteswOrganthatiotilltadividual V:
Address:
C ity/State/Zip: Phone#:
Are von an employer?Cheek the_appropriate box: Type or project(required):
1.0 t sot a eaipa,ar wail emetoyeesi(full anifur partvrinieh* 7. 0 New construction
1E3 i sin a idle proprietor or portnerstap anal have Ito einpko5set o,orkutv for rne In 8.I?Remodeling
any capacity.[No workers'vamp.insurance required.]
' 9. :Iir DettiOlition
I t'Or 1 am a horenownier doing all work myself.INO workers'Canc..itUtlatati...-t rtviartal
i 0 El Building addition
4.0 I ant a homeowner and will ho Minng 04411tZtitlft ED evatiduct all work on my property. I will
entire that all'Wan either haw workers'ctimmematiern insertmen or am sole i i ti 4 Electrical repairs or additions
proprietors with no employees.
i 2.0 Plumbing repairs or additions
5C3 Ism a general cnraraenir and 1!law hired the rabwthatatelors listed on the adaithed sheet
t 3{:j Rohl repairs
Thew:othwontractors have eimployars and lea worker's'comp.insurance.7,
I 4.rnOtherTt\3 ‘-)Li-A TIO kJ6.0 Wi...-aro a esattperalilLtil and its offiten have ekertrised than right of exam:rim per lii/GL e,
I Oh and-c hive nu employees.[N workers"ethrtp.insurance regal:red.]
Any appliiiitt that easdles ties 41 mad also fill out the warrant below aloe:eat their workers oompernation policy inifotiniatum_
P tiontenothers who submit this affidavit mthearag they are thing all ar lath and thwa hire(abide ecitabactors mud inionit a new affidavit indkunag mach.
1;Contiractom that.4:heck this box moat atrathed an additional sheet showing the name of the ractors and taie vi:hthher or not rhutio onlititn‘hate
employees if the sub-counselors laiwe ormloyees.they most prey ide then markers'omnp,wiee'!„number
,, .. . .. ,
lam an employer that is providing workers'compensation insurance far my eittplaree.s. Below ii the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lie.#: Expiration Date:
Joh Site Address: City,,State:Zip:
Attach a cop) of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c, 152,§25A is a criminal violation punishable b a tine up to$1,500.00
=dor one-year imprisonment,as well as c,ivil penalties in the form of a STOP WORK ORDER and a tine of up to S250.110 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigation,s of the DIA for insurance
coverage veritication „....... . . , , ..
.
I do hereby c y wider e poi -and penalties ofperjury that the information provided above Is true and correct,
Stenattire: ' Dote.' ixlg-31a- /
Phone
Official use only., Do Hat write itt this area,to be completed ht'city or town official
'--,',
ICity or Town: PertnitiLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Planibing Inspector
6.Other
, .
Contact Person: Phone#:
r
City of Northampton
�_` Massachusetts
\ DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ���
Northampton, MA 01060 341 . 10%
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, c-- Pc.-v! G /(-71-/ (insert full legal name), born _ (insert month,
day, yea hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this a3 day of Dec , 20 9).
(Si atur?)