38A-129 (7) BP-2023-0131
104 MOSER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38A-129-001 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-2023-0131 PERMISSION IS HEREBY GRANTED TO:
Project# BASEMENT RENO 2023 Contractor: License:
Est. Cost: 40000
Const.Class: Exp.Date:
Use Group: Owner: KANNAN COE, TERRENCE M&JAYALAXMI
Lot Size (sq.ft.)
Zoning: PV Applicant: KANNAN COE,TERRENCE M& JAYALAXMI
Applicant Address Phone: Insurance:
104 MOSER ST
NORTHAMPTON, MA 01060
ISSUED ON: 02/06/2023
TO PERFORM THE FOLLOWING WORK:
BASEMENT RENO
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: , ,
(If
Fees Paid: $260.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
IC Cot ( witeA., body , ,r_r-i..--,, ,, -
FEB - 2902
The Commonwealth of Massachusetts
li!of r Board of Building Regulations and Standa� __ �.. FOR
r of 6,1 ,1) ;'INSPr 1, ICIPALITY
h Massachusetts State Building Code, 70 CMl2�,�,_ ,, _ USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Buildinz
rmit Number: 6 P- d 3" l.15/ Date Applied:
1 a 4--.),
! 2.6 ZOZ3
� ��
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/ay /nosey 5-/: Nov' Mia.rigar mA 01D 1 3 f'A /act
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 PropertyDimensions:
PV Res?4.,t14I 6,i z3 liq
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® Private 0 Zone: Outside Flood Zone? Municipal L3 On site disposal system 0
Check if yes$1
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:lBrP.,�.A CM.- -r --lora/gik; cnnch Aia,--gclrnp4-o» 1 mA 01D60 i
Name(Print) City,State,ZIP
/Oy !Ylax&r s#. 88f64 -17sl /WI,te C.0 -7 -A"s•Car►, -
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Buildings Owner-Occupied$i Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units 1 Other 0 Specify:
Brief Description of Proposed Work': 13as<4m mi re,t+ovair o'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ s ct 600 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ Ili 4/0° 0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ /5 2. Other Fees: $
4. Mechanical (HVAC) $ 3,000 List:
5.Mechanical Suppression)on) (Fire $ ,7,000 Total All Fees: ` • 0
PP ) `pt1�"
Check No.(U Check Amount:
6.Total Project Cost: $ 4/0,OOd 0 Paid in Full ❑Outstanding Balance Due:
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
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 0 No .0
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 in this application is true and accurate to the best of my knowledge and understanding.
R/a12v23
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"
City of Northampton
rrf, Massachusetts :�
xx
DEPARTMENT OF BUILDING INSPECTIONS
11)
212 Main Street • Municipal Building ti na
Northampton, MA 01060 SSPky \�
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: MrN?mar? Trancfpr ctatinn Snringfialri �M
The debris will be transported by:
Name of Hauler: Green I eaf flicpncal anri Rerycl ing
Signature of Applicant: `iij�� Date: ;;1Q126723
The Commonwealth of Massachusetts
wog
Department ref Industrial Accidents
�I" `1
I Congress Street,Suite 100
�z�=:
tt� i'i, Boston, MA 02114-2017
tK wwiv.ntass.goi'/dia
II-a/lters'Compensation Insurance:%flida%it: BuildersF('ontractorslElectricians/Plumbers.
"1O HE FILED to t1 t1't 11EE FERMI[TING All'1?IOkrfl.
.tttltlicatit Information Please Print Lc_tibbi
Name tBusiness'Orrantrabon'lndtviduali-�
Address:
City/State?Zip: Phone#:
.'trr sou an employer'Chick the appropriate hut: Type of project(required):
1.C]I am a employer with employees(full and/or part-timrl-• 7. Q New construction
20 I am a sole proprietor or nat'tnership and hate no critployees working for ow in II•. El Remodeling
any capacity.[No workers'comp.imuramx re+quarcdj
30 I am a horisoowner doing all work myself.{No warktrs'comp.assurance imputed.)
9. ❑ Demolition
I O[3 Building addition
4.241 ant a lantaonwru^r and will be hiring oorunacYun to conduct ail work on my property. I will
c-rsure that all contractors either Itaoe workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietor.with no empluxcc^.a.
12.0 Plumbing repairs of additions
S I am a general contractor and I lame hired the sub-contractors listed on the attached sheet_
13.❑Roof repairs
Chess sub-contractors hhas*:cnnpluvices and heave worker.'comp.insurance.:
b.❑w'c a a corporation and ib officers hate exercised their nghl o r exemption per VIOL c. 14. Other
n
151 611 Al.and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks hat al must also fill out the section below show ins their workers'compensation policy information.
tknneuwnemm who submit thus atlida it indicating they an doing all work and then here outside contractors must submit a new affulas it annealing such.
'Contractors that check tht,box Must attached an adclauunai sheet showing the name of the sub-contractors and state whether or not those entities base
employee, if the sub-cuniracrurs Iv oc employees.they,mull provide their workers'comp.policy number.
I am on employer that is providing worAers'compensation insurance for an'employees. Below is the policy and fob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip: i_ -..................__._..
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MMGL c. 152, §25A is a criminal violation punishable by a fine up to S11,500_00
motor 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hc'rcbrl cretin lcr the puuiillsss uI:d penalties of perjury that the information provided above rs true and correct.
Sienatarc/�",G,!�' �%�( Date: ./ C)().2
Phone#:
Official use only. Do not write in this urea.to be completed by city or town official
('its•or Town: PerrWLicense#
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.C➢tyfTown Clerk 4.Electrical Inspector 5. Plumbing inspector
6.t)ther
(,intact Person: Phone#:
City of Northampton
s,c.
Massachusetts �? '��,
* G
tx. , DEPARTMENT OF BUILDING INSPECTIONS y f
212 Main Street • Municipal Building •;
Northampton, MA 01060 ssfrj r '
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, mac- m, /iY/���,
(insert full legal name), born (insert
month, day, year), hereby depose and state the following:
1. 1 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 roject 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. 1 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 onet 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 2 day of FeIrt•,ary ,20 23
(Signa re)
'/2/"j Ceiling projections (support beam/HVAC)
® Smoke/CO detectors
® LED recess cans 6"
Access panels
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