25C-033 (3) 33 NORTHERN AVE BP-2021-1286
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-033 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 P E RM I T
Permit# BP-2021-1286
Project# JS-2021-002134
Est.Cost: $8700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10018.80 Owner: PRABHAKER SUMANTH
Zoning: URB(100)/ Applicant: PRABHAKER SUMANTH
AT: 33 NORTHERN AVE
Applicant Address: Phone: Insurance:
33 NORTHERN AVE (617) 319-0133 ()
NORTHAMPTONMA01060 ISSUED ON:5/7/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:BATH RENO, ADD 1/2 BATH AND CLOSET
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:
S
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•'f • )2
FeeType: Date Paid: Amount:
Building 5/7/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
2 -OK
File#BP-2021-1286
APPLICANT/CONTACT PERSON PRABHAKER SUMANTH
ADDRESS/PHONE 33 NORTHERN AVE NORTHAMPTON (617)319-0133 Q
PROPERTY LOCATION 33 NORTHERN AVE
MAP 25C PARCEL 033 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT (�
Fee Paid _
Building Permit Filled out
Fee Paid
Typeof Construction: BATH RENO,ADD 1/2 BAT ND OSET
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
X 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
Demolition Delay
, / lir
10 / C/10/A,
Sign;ture of Building Official I 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.
J Fi'------ -a-E--7---------/V&L)
The Commonwealth of Massachusett MA
I , Board of Building Regulations and:"Stan rds ` 5 202/ OR
Massachusetts State Building Code, 780 e�� USE ITY
kilt
Building Permit Application To Construct, Repair, Renova'be'- 'e A OoA, Rev; ed Mar 2011
One-or Two-Family Dwelling �' _
This ection For Official Use Only
Building Permit Number: 6n A " a Date Applied:
( i ' 1 "SI, T°11P,
Building Official(Print Name) ' Signature Date
SECTION 1: SITE INFORMATION
1.1 osty Address: 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
pSv vv.as.N'k-LN Qr abINm.K,— NO(111. A, 'fO ►. AU OI O6t
Name(Print) City,State,ZIP
3 3 Nn re-'rtk-beiN lovvit ` 17-3 14-0 I33 svwA.A►'t+L.frAW,4kefgd 4A3(ow`
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 10 Owner-Occupied 0 Repairs(s) 0 Alteration(s) a Addition 0
Demolition Er Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Propose_d Work2: k c,M/LC1-pl.,a c.f e 3/'�:'`% g c.,k U, i 73-v'✓L,. _ y,0i1
�_ � _ y, h
.. Gel �'�.. .,' "I b 14- !�. C,r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ fid 1. Building Permit Fee: $ 45. Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee 9
50 0 Total Project Cost3(Item 6)x multiplier x 6,fo
3.Plumbing $ "I C b 2. Other Fees: $ •
4.Mechanical (HVAC) $ ' (fi:) List: r Q
ii
5.Mechanical (Fire V` k
Suppression) $ Total All F C�' °'`' ✓ C
Check No.Q� Check Amount: 65 Cash Amount:
6.Total Project Cost: $ b.. 7 ') 0 Paid in Full 0 Outstanding Balance Due:
' 1
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 Issuan a 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.
Suv iv Rbk
er /2- 7I2 '
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 in this application is true and accurate to the best of my knowledge and understanding.
Survah Pra6I,Ak,e...r I /27 /21
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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" Li C
The Commonwealth of Massachusetts
_ 1, Department of Industrial Accidents
1- 1 Congress Street,Suite 100
__14-_ ' Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): So."nnk'tt Qr Hyl,,,1:Q,r
Address: 3 3 ki o e iri e r v. )t v-e+,kre
City/State/Zip: N o( '14^ c'"'f k o v. MA 0106 D Phone#: 6 1 T "3 t ci - 01 33
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. TRemodeling
any capacity.[No workers'comp.insurance required.]
9. l'bemolition
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 Building addition
4.11 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
p
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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.
Iam an employer that is providing workers'compensation insurance for 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).
ailure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
' I do hereby certify u • the pains and penalties of perjury that the information provided above is true and correct.
Signature: f ' /1,/ __ H /2 7/2 k
���/ '' Date:
Phone#: 6 II ' 3 °l- 0 `3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
6\, 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#:
City of Northampton _
Massachusetts „
N
DEPARTMENT OF BUILDING INSPECTIONS ti '
dae 212 Main Street • Municipal Building ilti,
Northampton, MA 01060 "1'1Y 3,'`,\
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: C 41r l S ut� CI- to
Y - �
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: 11 /21i 21
City of Northampton
. Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS <°
212 Main Street • Municipal Building
Northampton, MA 01060 :7��
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, 453
Juw�au��'1^ �0,131o�k (insert
(insert full legal name), born nsert month,
day, year), 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 qualifij 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 27 day of A r" I , 20?t.1 A _Alikk
r
4
(Signature)
City of Northampton
H,�_MpTOI S S
�' "' Massachusetts ha��'� .r._ ��'e,;,
* C,,
iF „) .v 3
d '� = DEPARTMENT OF BUILDING INSPECTIONS A.1. it
` �' , ;>' 212 Main Street • Municipal Building Jtis 6�D`
nr.,_y Northampton, MA 01060 'J -a •'
e- Q C 1 Otvii,y
7 C61- -) 9- 133 9
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 &2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
33 No-riteviii, f ���
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.
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.
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