29-495 (7) BP-► 022-0969
405 RYAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-495-001 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-2022-0969 PERMISSION IS HEREBY GRANTE I TO:
Project# ALTER POOL HOUSE Contractor: License:
Est. Cost: 1000
Const.Class: Exp.Date:
Use Group: Owner: ANDRIKIDIS C PHILIP& SHELAGH PAYANT
Lot Size (sq.ft.)
Zoning: WSP Applicant: ANDRIKIDIS C PHILIP&SHELAGH PAYANT
Applicant Address Phone: Insurance:
405 RYAN RD
FLORENCE, MA 01062
ISSUED ON:08/12/2022
TO PERFORM THE FOLLOWING WORK:
INSTALLING WINDOWS AND DOOR ON POOL HOUSE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.VV. 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 VIOL• TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
' I
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/T4
0
The Commonwealth of Massachusetts os ' , S/
IF lt , Board of Building Regulations and Standarek ti o / .
Massachusetts State Building Code, 780 CMR °9TyoG , 4471>p,1L ITY
9 !
Building Permit Application To Construct,Repair,Renovate Or ► •r a 'vised ,ar 20
One-or Two-Family Dwelling °ti)'2s
117 This Section For Official Use Only °,�>
Building Permit Number: - qO 9 Date Applied: ° s
Vesvl&-) /1Z7t: _//72 6-,Z-ZOZL
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessorsss Map&Parcel Number L^�
405 Ryan Rd. Florence,MA. `T �f
1.1a Is this an accepted street?yes X 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
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:
C.Philip Andrikidis Florence,MA.01062
Name(Print) City,State,ZIP
405 Ryan Rd. 413-262-8007 florenceroofingagmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:Close in 3 walls on existing pool house. 2x4 construction installing 2 windows and a door.
V Pe4cTOR . 27
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ 63 000 Check No.. Check Amoun Lt Cash Amount:
6.Total Project Cost: $ t eee ee 0 Paid in Nil ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 071107 4/24/23
C.Philip Andrikidis License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) 11
405 Ryan Rd.
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
Florence,MA.01062 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
413 262 8007 SF Solid Fuel Burning Appliances
florenceroofing@gmail.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 01573 8/26/23
C.Philip Andrikidis/d/b/a Florence Roofing HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
405 Ryan Rd. florenceroofing@gmail.com
No.and Street Email address
Florence,MA.01062 413-262-8007
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 provi'e
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes la No Cl
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.
C.Philip Andrikidis ( 8/11m
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/tips
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fmished 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"
` The Commonwealth of Massachusetts
w Department of Industrial Accidents
' 1 Congress Street.Suite 100
t�
Boston.MA n211 4l-2017
fi1,4,,
stirmnrass. or/dia
' ,t 11r»kcrs'Compensation Insurance Affidavit:BuildersdContractorsiEkctrkians1Plumbers.
't'l)1W Ell.En IA II n THE PE:K%It rl IMG AUTHORITY.
Applicant information Please Print I.t ilrls
Name tiiusaucs.sOrs:•l tt:mon lndtvatluatl: C.Philip Andrikidis/d/b/a Florence Roofing
405 Ryan Rd.
Address:
Florence,MA.01062 413-262-8007
(It% State Zip: _--__ ___--_-.__ Phone :_-_
lee!ors an employcr.!t.heel.the a.prreoirrr:starrhaw TYPe alley*.
..^.J,I am a enrrploycr wit•h 5 employs.gull and or part-him).* i 7. 3 New conalruetto
2.....1 i am a sok p of rrrhx or pactnenal p and law no cur toy oz.woe!rm; tw sac m N. 0 Remodeling
any capacity.[No Audios'comp.insurance required./
9. D Demotetuc n
t. tam a gunman. em dorm all work am.01 '\.o w.lalc."eonr tauwraawc coquina as 1"
Ili 0 Budding addatso
t, l am a huns.r w nce and w ill he honing oontracturs to caeuiraa'l Alf week on my propery. I wit!
.._.1 ensure that ail contractor,either has..worker.'cunrp►Yn.atrun insurance or are uole ; I I 0 Electrical repairs or additions
proprietor,earth us,.crrlt•'se...es.
I2.0 Plumbing repairs or additions
I am a evaeial(o''dractoor sad I has a hind the w!+-easurract;..r.mural on theanached.hies
113..Dlitoof repairs
lite,:web-coenza:tor.law e empk l.ccu:xudltun c worker,'cawsr.insurance
i4.®Othe'i
6.0 c arc a corporatnoa MA:IN o f f ter.bat a e t encrucrt then nicht of ce.nrfexr per%t(it_c. --_.�_._--
ty_'.f1 It41.and we haw.no❑irk.)oc..(No worker.'co rp.Insurance required_]
'Any applicant that checks box ai must ai.w till out the secliun below shnwins nicer wIlltida3.curnpcnsatsun policy information.
*P.taecrcvwren.who submit dm.:drub.rr i:rducafmg they arc doeng all work and them hire outside evegractors m u.r unixad a new afrids+c it real,► x"AAA-.
:('uv rsactasa t aL check.diem boy annul an .Rs:-d,an.d:an a l sheet dumber:tic anus[.Addle sue eewa'ae'te re.and state w ilcdtet or out tltees,c Anne 3asc
cirtrloyce,c tf du:wah,coritr►cein,l n e cearplone..-..the..nmm.n ran iatc Own +wrier;*Amer.r.9tco enuamtscr
i
/am an employer that is providing worAers'compensation insurance for my employees. Below is the police'and job site
information.
Insurance Con►pu►y Name: Liberty Mutual Fire Insurance Company
Policy#or Self=ins.Lic.;:: WC2-31S 374455-052 Expiration Date: 01/25/2023
405 Ryan Rd. Florence,MA.01062
Job Site Addraac: _-_ City/State�ZlP: _
Attach*espy of the workers'compensation polity,declaration page(showing the polity number and expiration dint).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal l rotation punishable by a fine up to SI.50().00
and'ur one-year imprisonment.as s►ell as col it penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the l iolator.A copy of tins statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage l eritication.
I do hereby certifyunder Me pains and penalties of perjury that the information provided above is true and correct.
Signature: Uatc: 8/11/22
413-262-8007
Phone
Official use only. /)a ncit write in this area,to be completed by city or town off its-t
City'or Town: Permit/License#
Issuing Authority'(circle one):
I. Board of Health 2.Building Department 3.City/Iowa t'ierk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4: _
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 U al'� iC
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant