23A-145 (3) 140 PINE ST BP-2019-0942
GIs k: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A- 145 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING ILDING PERMIT
Permit# BP-2019-0942
Protect is JS-2019-001574
Est Cost$5000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sg.fl.): 96703.20 Owner: Robert Gougeon
zoning:01 Applicant: C PHILIP ANDRIKIDIS
AT: 140 PINE ST
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
FLORENCEMA01062 ISSUED ON.3/4/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 9 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:
FeeTvpe: Date Paid: Amount:
Building 3/4/20190:00:00 S100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Vcr aonl.7 Commercial Building Permit May 15,2000
.Department ttae oMy
Northampton Status Of Permll:
RECEIVED Bu'ding Department Curb 2 utlDrinsomy Permit
12 Main Street Sewn/Septic AvallebNty
MAR 4 2019 Room 100 WawwaNAvalW ty
orth mpton, MA 01060 Two Sets ofstruchow Pwre
3-5 7-1240 Fax 413-587-1272 PWSVOA..P�lait's
PFPT OF f,II O,,,IN5PFCTIONS OliverM•r
M 1"50
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: �j This section to be completed by ofNcs
No 1 f G `�t v�2- 4. Map 9:v A Lot I tis Unit
Zone Overlay Disbict
Elm St District CB Distinct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Gainer f Record:
Name e oN LGdd t o�oc
y/ „ eiling Address:
� _.. . C anenttMM� 6 3
Signature Telep one
2.2 Authorized Agent:
C. , \ . r,.,�,� '}r,r,�.✓tiC.o�S '/ria'— �-c+'
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by pennit applicant
1. Building S�IOO t� (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
6. Total=(1 +2+3+4+5) Check Number 143i i�
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
r 3 -LI-Z01�
Building Gomrriisalsionerllnspe or of Buildings Date
Vemion1.7 Commercial Building Permit May 15,2000
SECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing® Change of Use❑ Other❑
Brief Description Enter a brief description fh�ere.
Of Proposed Work: ' '4y I> ,r roc+ w/ t= j>L)M
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 16 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ I-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 5 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1` 1.,
2" Z
3� V
4° e
Total Area(sO Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
B. NORTHAMPTON ZONBNG
Existing Proposed Required by Zoning
]bis column to be Mist in by
Building Depznmem
Lot Size
Frontage
Setbacks Front
Side L:- R: L:- R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Wt amu minus bldg£
parking)
#of Puking Spaces
ccs
Fill:
wlumc&Wcndon
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O 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 O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is i1 part of a common plan
that will disturb over l acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Perntit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,090 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant.
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Data
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Eviration Dale
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name'.
Responsible In Charge of Construction
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No 0-
SECTION II -OWNER AUTHORIZATION-TOBECOMPLETEO WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
y 1 6i" ('�e,,n as Owner of the subject property
hereby authorize C \ V)J(P 1"rr�r( �.to�S to
act my behalf,in all matters relative two work authorized by this building permit application. c,
i55reture' orowder Dale
I, C• l' �^.�r Y'T^� I �r of �$ ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application am true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Pdnt Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holden. C 'P�•('n 67110-7
License Number
Address Expiration Date
Sd3'—C//71
SigneNre Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152.1 2SC(8))
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 O No 0
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: 1`/o i1.-Z� fl
The debris will be transported by: t ( ,,� Imo
The debris will be received by: Vrt I k y D�
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth ofMassaehusetts
Department of InehistrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
T—
www.mass.gov/dia
Workers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoulieunt Information Please Print Leeibly
Name(Business/Organization/mdivldmp: G -F>h,l,, t/.r^t{.a_ot . k, relf\
Address: a/Dc— P-lor w fid/
City/State/Zip: `- 1,,, , c-e Phone#:
Are you an employer?Cheek the appropriate box:
Type of project(required):
1.E31amaemployerwith employees(foll and/or parttime) 7. []New Construction
2.�amasole pmprietoror pennership and havememployees working formum g. ❑ Remodeling
any capecity.[No workers'comp insurance reyune f]
3.❑1 am a homm veer doing all work myself.[No woders'Doom.insurance requi d.]t 9. ❑Demnng addition
4.❑I am a bomemour and will be hiring contmcms.m conductall work on my property, t will ]OQBuilding addition
ensure that an eouvacrma either have workers'compensation insurance or are sale 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5,0 1 am a general emaractor and I have hired the sub<rnnacmm listed on the attached sheet. 13.�Roof repairs
These sub-emanon a have employees and have workers'comp.insmance.
6.❑We are a coMomfion and its officers have exemised their right ofcamrston fact MGL a 14.❑Other
152,§1141,and we Imveno employees-[No waders'comp.hamance"mood.]
*Avy applicant that checks box kl must also fill out the salon below showing their workers'emng o.ton polity i ammo wn.
t Hommwms who submit this affidavit indicating they are doing all wod and then hire outside emurnmans must submit a new affidavit indicating such.
tCo mmens that check this box most attached an additional sheer showing the more,ofthe sub-commetom and state whether or not those enfities have
employees. Ifthe subenmmeters have employees,they must provide their woders'wmp.policynumber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
informa imi.
Insurance Company Name:
Policy#or Self-ins.Lia#: 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).
Failure 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 under the pains Cara! ' r ury that the btformadlon provided above is true and correct
S true' Date'
Phone#'
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
C.PHILIP ANDRIKIDIS DBA
405 RYAN ROAD, FLORENCE,MA 01062
INSURED BY KING&CUSHMAN 4133845610
HIC #150673
CSL#171107
MSL#11282
1 request that you grant a modification to waive the requirement for control construction for
the project at 140 Pine SL Florence because the work is of minor nature,and will not affect health,
accessibility, life,fire safety, and is impractical in that the cost of control construction is considerable when
compared to the cost of proposed work. Thank you for your consideration.
Respectfully,
C. Philip Andrikidis
Florence Roofing
405 Ryan Road Florence MA 01062