31B-277 (4) -,, The Commonwealth of Massachusetts
_.,
. Department of Industrial Accidents .'
'-- � Office of Investigations .
600 Washington Street %
-!2;...--7=7E--------- Boston, MA 02111
,
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. 7 r ° www. mass.gov /dig
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): C r" � Y' ,
'. ' . t 1 k C
Address: S Z s , r, t�
City /State /Zip: ' 1 �•.. -(? : -- ,1 vt fl ' � Yhone #: }j -, - 1 i
Are you an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part- time).* have hired the sub- contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
for me in any capacity. employees and have workers'
working Y P h'• 9. 0 Building addition
#
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers'
13.0 Other
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 him 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.
I am 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).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 t ains and penalties of perjury that the information provided above is true and correct.
Signature: e--- , Date L ill-
�- j
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 #:
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10- ,STRUCTURAL PEER REVIEW (780 CMR.110.11) ,
n
Jr
Independent Structural Engineering Structural Peer Review Required . Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f
I, �4 ..l: r`) 1. �. .. _.. u m ... , as Owner of the subject property
t i R _ ,, 1,� , l ,,r*" t d ,,S
.! �i .s �, ..v . �, ._ � d _ ._a.. M _a. , w_
hereby authorize _ � ..___ to
act on my behalf, in all matters relative to ork authorized by this building permit application. �( ___ _ __ _
Signature of Owner i Date
morm ... iiiiiiiii i ii i iiimiffiriiiiii_____ _____
--
I, ,.____� .._�_._'� I ' •• .t ,,,t. . . ".' �.'�z; �_ -_ *L " ,� _.... ....�......._._._. , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u _
Print Name _....... _________ _,.w.__.,_.
Signature of Owner /Agent Date "�.VV/
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . _... r� Y _ t ( . m ,. 'L .. _...: - � b".,_..._,.�_. �e. _
License Number
.,,,,, ,____,... _ ...____ .. . _.._._ ".."
Address ` Expiration Date
Signature Telephone
SECTION 13 - 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
•
Q,
Version1.7 Commercial Building Permit 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 35,000 C.F. OF EIJSLOSED SPACE) . __
r
9.1 Registered Architect: •
Not Applicable ❑
Name (Registrant) 6 --
Registration Number
Address I
. __ Expiration Date
Signature Telephone
9:2 Registered Professional Engineer(s):
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
i I
Signature Telephone Expiration Date
-- ,.-.. -._ .
Name Area of Responsibility
Address Registration Number
(
Signature Telephone Expiration Date
Name Area of Responsibility
__ _ ___._m
Registration Number
Address
I
Signature Telephone Expiration Date
9.3 General Contractor
__.__ — _w.__ _,_._ _____.__i Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_ Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
•
t
Existing Proposed Required by Zoning
4 This column to e filled in by
Building Department
Lot Size _____ ,.�... ,.... , .
M1 + _____ _
Frontage _m_ __ , ___ ___._ ____ .,_
Setbacks Front w.. —
Side L:` — R:. L: I R; 1 1 .. _
_
Rear _ _ 1
Building Height --"
Bldg. Square Footage _ £__
Open Space Footage % --
(Lot area minus bldg & paved
parking)
# of Parking Spaces I
Fill: ,_ ;
(volume & Location) .. ---
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ' t Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: t
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. WII the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
4 s
lb
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE T x Y , t _I
Interior Alterations ❑ Existing Wall Signs ❑ Demolition 0 Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofin Change of Use ❑ Other ❑
,.
Brief Description 4 Enter a brief description here.
Of Proposed Work .f.,;V ! ( ,f ' a
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1 A I 0
A-4 ❑ A -5 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C 0
H High Hazard 0 _ _:_ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -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. j _ �..,,.�.. ,....... ��.d.._..m _ .,...,.�.._.
S Special Use ❑ Specify: i
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. 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
.. „. 1 st
1
�1
_. _ _._____�.._.._ _... 2n t
2
3rd ..._.._ _.._ .._ _..__ 3b -I
4th 4th
Total Area (sf) Total Proposed New Construction (sf) _
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 F1ood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone ___,____ Outside Flood Zone❑ Municipal ❑ On site disposal system
�- ■�, Version 1.7 Commercial Buildin_• Permit May 15, 2000
"'riC ` s Departmght a ty
City of Northampton P�
�i 2 A ( 012 - Building Department ® CuUDn ewa Per
212 Main Street
oHS Room 100 erI1 atiabllityNM�
oFeu�>o "oi�uso �rthampton, MA 01060 pct r��fa$ a$��
N phone 413- 587 -1240 Fax 413 - 587- 1272�t�teians
u er SpeE6fr a ;
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:
This section to be completed by office
A-\ `i � 2l t j 1 " v: i t3 +k °r t ` Map Lot Unit
1 " �� �1 • Zone Overlay District
iltni ?�� e Oli� G )
... Ww Elm St. District CB District
SECTION 2 PROPERTY OWNERS .HIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Signature / Telephone
2.2 Authorized A edit:
C 11 i ✓�1L.c� -' t
W_.v....._....�
Name (Print) Current Mailino Address
Signature / Telephone
SECTION 3 - .ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1._ Building (a) Building Permit Fee
2. Electrical _ (b) Estimated Total Cost of
_I Construction from (6) _...._...._
3. Plumbing € Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This ,Section P:For Official Use Oniy
Building Permit Number Date
Issued
_ Signature:_ _
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0835
APPLICANT /CONTACT PERSON C PHILIP ANDRIKIDIS (�
ADDRESS/PHONE 52 MAIN ST FLORENCE (413) 585 -9171 y 1
G �
PROPERTY LOCATION 51 STATE ST 6
MAP 31B PARCEL 277 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out !J' _• 161 y
Fee Paid Q o
Typeof Construction: STRIP & REROOF W /TPO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 071107
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
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
lition Delay
Signa e of Building Of icial 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.
51 STATE ST BP-2012-0835
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 277 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 PERMIT
Permit # BP- 2012 -0835
Proiect # JS- 2012 - 001476
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 7579.44 Owner: COOPER'S DAIRYLAND OF NORTHAMP
Zoning: CB(100)/ Applicant: C PHILIP ANDRIKIDIS
AT: 51 STATE ST
Applicant Address: Phone: Insurance:
52 MAIN ST (413) 585 -9171
FLORENCEMA01062 ISSUED ON:4/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & REROOF W/TPO
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:
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:
FeeType: Date Paid: Amount:
Building 4/2/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner