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23A-151 C.PHILIP ANDRIKIDIS DBA 52 MAIN STREET, FLORENCE, MA 01062 R00FINiGs INSURED BY KING&CUSHMAN 413-584-5610 HIC #150673 CSL#171107 MSL#11282 I request that you grant a modification to waive the requirement for control construction for the project at 98 pine street in 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. Phili ndrikidis Florence Roofing 045 Ryan Road Florence MA 01062 <, The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 4 „ 600 Washington Street x Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/C on tractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C i(!� 'tr VL4C t CU _ Address: C/GS City/State/Zip: 14 'l one#: SAS" Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction -2.&I am a sole proprietor or partner- listed on the attached sheet. 7: ❑ Remodeling . - These sub-contractors have ship and have no employees 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.1 required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions �.❑ I am a homeowner doing all work ❑ myself. o workers'comp. right of exemption per MGL y [N p 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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 hire 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 the pains and Ities ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Of use only. Do not write in this area,to be completed by city or town offcciaL ------ —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#: Y Version L7 Commercial Building Permit May 15,2000 a SECTION 10-;STRUCTURALPEER REVIEW(780 J CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes R No 0 SECTION 11 -OWNER!AUTHORIZATION 4T01 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, "y�l�� 'Y\ �► w___ . ___d___. ... _,5,as Owner of the subject property JJJ > hereby authorize: �..._.m... .. ____.____.,__....__. ..... . ..... ........__.. o act on my matters relative to work authorized b t building permit application. Signature of Owner to 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..under the pains and penalties Aofpeury - r , Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ M _ Name of License Holder: - License Number Address Expiration Date Signature Telephone SECTION 13'-WORKERS COIVIPENSATION 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 Versionl.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 CMR1116(CONTAINING MORE THAN 35;000 C.F.OF EWLOSED 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 __..... .._ i ....... ._....._...__ .............__. . ..___._____ __..._ _.. _,._____... ___. . __. _ . Address Registration Number Signature Telephone Expiration Date ...................._....................__....__._.._.._......_..._.._...._............._...._....__. . Name Area of Responsibility Address _ Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date i 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 Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning . This column to ge filled in by Building Department Lot Size Frontage Setbacks Front Side L' R. _ Rear -- Building Height Bldg. Square Footage % Open Space Footage _ % - — - =_ (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) - - - -- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW 0 YES 0 -1F YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0m IF YES: enter Book ` 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 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: .._........-__.........._.................... _..............................._.._...."_....._._..........__......__.._._._"_......._...............;: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will 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 2 Northampton Storm Water Management Permit from the DPW is required. Version l.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❑ RoofingW Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work:r 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 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 28 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard El - — - - 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 36 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify::f M Mixed Use ❑ Specify S Special Use ❑ Specify. _ .......w..,.-_�_,.._,.-.....�d.....�,........�.z.v.w.._.,�.._,. ._,_.__�..__�,..M...._.�.___.�._. .a.�e, COMPLETETHIS SECTION IF EXISTING''BUILDING UNDERGOING RENOVATIONS,ADDI-TIONSAND/OR.CHANGE IN USE i 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(so ist St __ .__ ____..... ...............Y....�_..._.. ._.., 2nd ; 2nd _..........._,__...__________.._...._....T_.? ._..... ..... .... . 3d 3rd _... _.w_ _ _ __,. 4m 4'" 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 Flood Z one,Information: 7.3 Sewage Disposal System: Public Private ❑ Zone _ Outside Flood ZoneEj Municipal ❑ On site disposal system Versionl.7 Commercial Building Permit May 15,2000 Departure t use,only I m City of Northampton status of Permit c°v l;L Building Department Curb CuttDnveway Fermis r` 0 ..) 212 Main Street Sewer/SepficAvailabtlrt}r 24- Room 100 WaterMfell Avarfabihfy m Q qI Northampton, MA 01060 Two`Sets of Structuraf Plans 0 phone 413-587-1240 Fax 413-587-1272 PlotlS�te Plans �n Other Specify APPI N 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 q b ` Map Lot Unit Zone Overlay District -- Elm'St.District CB District" SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Own4 of R ord: Name(Prin t) Current Mailing Address: Signature + h1�'r2 Telephone d 2.2 Authorized Agent: Name(Print) Current Mai ling„Address: _ Signature �/ Telephone SECTION`3°-ESTIMATED!CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building - TY; ,Jv € (a)"Building'Permit:Fee ...:. ..... ,. ._. .. ,. _ .....__.. 2. Electrical (b) Estimated Total Cost of Construction from 6: _._ _._._. ... --- 3. Plumbing i Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use 061 Building Permit Number Date Issued Signature:-- Building Com miss ioner/Inspector.of Buildings Date File#BP-2014-1224 APPLICANT/CONTACT PERSON C PHILIP ANDRIKIDIS ADDRESS/PHONE 52 MAIN ST FLORENCE (413)585-9171 PROPERTY LOCATION 98 PINE ST MAP 23A PARCEL 151 001 ZONE URB000V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: STRIP&SHINGLE ROOF 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 INFO jMATION PRESENTED: pproved 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 olition Delay Signature of Bui ding O ficial 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. 98 PINE ST BP-2014-1224 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 23A- 151 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-2014-1224 Project# JS-2014-002064 Est.Cost: $7300.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: C PHILIP ANDRIKIDIS 071107 Lot Size(sg.ft.): 24306.48 Owner: 98 PINE STREET LLC zoning. URB(100)/ Applicant: C PHILIP ANDRIKIDIS AT. 98 PINE ST Applicant Address: Phone: Insurance: 52 MAIN ST (413) 585-9171 FLORENCEMA01062 ISSUED ON.512112014 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# 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 5/21/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner