38B-164 (4) BP-2023-0913
24 FORT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-164-001 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-2023-0913 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 BATH RENO Contractor: License:
Est. Cost: 15000
Const.Class: Exp.Date:
Use Group: Owner: GUILFORD RANGAN POOJA G & JOSHUA M
Lot Size (sq.ft.)
Zoning: URB Applicant: GUILFORD RANGAN POOJA G &JOSHUA M
Applicant Address Phone: Insurance:
24 FORT ST
NORTHAMPTON, MA 01060
ISSUED ON: 07/13/2023
TO PERFORM THE FOLLOWING WORK:
BATH RENOVATION
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:
p' r
�` � i/ e i
Fees Paid: $97.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
/94r,s t
The Commonwealth of M. sac '.- 0 j a
Board of Building Regulations a : S a ,r. i ' R
W Massachusetts State Building Code, :4i :, . t. IPALITY
• USE •
Building Permit Application To Construct,Repair, Renov. 1)(' ?'- olish . R•,ised Mar 2011
One-or Two-Family Dwelling 414A>(11,
This Section For Official Use Only s
Building Permit Number: i3 a0a,3 - O 1)3 Date Applied:
(= .•, It ,g. ,r� 13
Building Official(Print Name) Signature e
SECTION 1:SITE INFORMATION
14 F -( sr. 1.2 Assessors Map&Parcel Numbers
1.1a 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) i Frontage(ft)
1.5 Building Setbacks(ft)
f 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 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Redic
jerirwAu l eke; Nen -T+fM r /4 i IM it 01 a b o
Name(Print) City,State,ZIP
244 FOAfr sr• 5j .-.'f O-Oi/1 i.skllua.. ailf-w„4Q jc ts44,(1.4'ae•
No.and Street Telephone u Email Wddress
SECTION 3:DESCRIPTION OF PROPOSED WO 2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repai s(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units er 0 Specify:
alifillErof Propose ‘4 P-fit "._)r Y Y 6Y ier1 l At
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item (Last,, t� Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total A F 97,36
,�` Check o.: heck Amount:
6.Total Project Cost: $ /5.) �/ 0 Paid Fill 0 Outstanding Balance Due:
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City of Northampton
to x_
Massachusetts
ai
� 1 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
'c.
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate(new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code .i);l new construction:(chit/Rehab)requires a HERS:WAIT Affidavit .
1O. Please provide the appropriate fee,in the foKm of a check made payable to: The City of•
Northampton.
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 .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. .
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"
4
The Commonwealth of Massachusetts
t
=litintat Department of Industrial Accidents
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—1111t6v 1 Congress Street,Suite 100
MI ato}.......
"":4)111 V ill Boston, MA 02114-2017
www.mass.govidia
1%inkers' t'o nipensation Insurance Affidavit BuildersiContractorsfElectriciatisfPlu whets.
11)OE FILED WITH IllE PEILNIFITINt;Airnioturty,
Annlicant Information Please Print Letibh
Name iausaless,organgzattorvitaioactuair
Address:
- .
City/State/Zip: Phone P:
- -- „,
Art ytitl an intallia er?Check the a pphapriate bon 1 i pc of project(required):
1.0 I ani a employer aratb , , , employee%(fill aridIiit part-timet.. I 7. Ej New construction
.0 I ara.a vole propane*ur partnerslup and base at employees working. tur anie xis S. c3 R.modeline,
.„airraicaty.[Nu wafters'comp.intantarier reitaital]
tie1 am a humaivaier dump al
n l work myself[No*parkins'emir_airearance reatithredi*
„0 1 ii a itinneowner and will he hiring‘VIIIrdedull to ootidLigt MI WorL on city preet*. I will
lj9. C:1 Demolition
100 Building addition intiare the all contract-oft either itaxe makers'manpotulion inawmaet:or aire solar 3 3 a Electrical repairs or additions
prupacticars with no einployen,
I 32,0 Plumbing repairs or additions.
30 I am a general contractur and I lime hired the sob-euritineturs Listed on the attached shisa
I BC]Root-repairs
Thaw sub-euntranurii haw cantiloyees and lime workers*comp.taisurancei
t i 4.1:1-Other
n_E]we an a anpornino and als.officers hese exercised then right of e„ierriptiam per
152.§1f4 a.and we base Vaal employees.[Nu sackers'comp,ilmtalinec umutral
'..
-Ai applicant that eitieks tiox I rnu also fill ma tibe%onion below hito4 inv them workers'compensation path anforrizatania
S Know%niers who whin du all-admit noticating they are dum all'.4 1 ark.and then hue outside containnes Mita Anna a new Aida%it aradimung itis.ti
Itaintracturs dna check this,box mui artaeaca an atialitional hhtei stunti inc the mum of aw,i.it unuauura and gate ix/tether in rail those entities lime
oriplo:‘eci if the suheunaractiirs leo e earployees,thet ruahl rnA ide ifik.i.r. "A orken'comp.paliey number
• „ ,.
I am an employer that is providing ovorken'compensation insurance for my employees. Below is the polity andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
iiiiii, rtploLt r. CitylStatelZip:
Attach a .. e workers.*compensation policy declaration page(showing the policy number and expiration date).
Failure to 4ttre coverage as required under MGL c. 152.*25A is a criminal violation punishable by a tine up to S1,5()0.00 d
amlior orre-year imprisonment,as well as civil penalties in the font cif a STOP WORK ORDER and a line of up to S250.00 dr
day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the [MA for insurance
c ii[Ix'ation,
I du hereby certify lift 1-the lPth/Ptnahies ofperjury that the information provided above is true urn!correct
Phone#:
Official use only,. Do not write in this area,to be completed by city or town officiiil
City or Tow n: PermitiLkense#
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#:
i li'
City of Northampton
Sri.
Massachusetts
lc
DEPARTMENT OF BUILDING INSPECTIONS y`s a '
`:4,; 212 Main Street • Municipal Building +3 .C2r~
Northampton, MA 01060
CTION DEBRIS AFFID
(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:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: 1- 1Z — Z-g
City of Northampton
tit�:�t'7,R��
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ? x'
212 Main Street • Municipal Building
Northampton, MA 01060
4
ELIGIBILITYAFFID R.'"'A eck 14. J
Jos/+ 6 {IL ►-n /Y(I '
(insert full legal name), born_ (Insert
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 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 s and penalties of perjury on this "2,day of J .' —11 , 20 2-?.
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( zgnature)