32C-142 (20) The Commonwealth of#Massachusetts
Department oflndustrialAccidents
r�r Office of Investigations K
600 Washington Street
Boston, MA 02111
- - www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors[Electricians/Plumbers
Applicant Information Please Print Leaib_ly
Name (Business/Organization/Individual):
Address: Lt v s
City/State/Zip: 444- Phone#: - S ` 7/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a with w
employer 4. E] I am a general contractor and I
6. New construction
employees (full and/or part-time).* have hired the sub-contractors
_ _2.1-1 I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling;
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑
right of exemption per MGL
myself. [No workers' comp. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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 penalties of perjury that the information provided above is true and correct.
Signature: Date: ,1 �y
Phone#:
Official Ilse only. Do not write in this area, to be completed by city or town official
--City or Town: Permit/License#
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#:
Version 1.7 Commercial Building Permit May 15, 2000
.a
t
SECTION 10-STRUCTURAL,PEER:R.EVIEW,(780 CMR 110.11)
11 1 .
.a
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 OWNER AUTHORIZATION-TO BE COMPLETED VIlHEN
OWNERS AGENT OR CONTRACTOR APPLIES F0R'BUILDING PERMIT
..............
___.... . . .__ _.. .... . .__.. .._. ... _.. .. .:,as Owner of the subject property
hereby authorize .. '' 1 ,-cat,. ��.�( _
act on my be If,in all matte rel 've to work authorized by this building permit application.
Signature of Owner Date
1._L IP.. r. r 1.....�_.,....._ _ _ _..._.. ._..,: 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 of perjury: _.. ..... _. _.. .
ct L.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES -
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holde ?!;;A„ #C>776
vv,
License Number
Address Expiration Date
Signature Telephone
SECTION 1.3 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.Li 6.152,§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 t e building permit.
Signed Affidavit Attached Yes No 0
Version l.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 EKLOSED 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
:... .... ........... ............ ......_.. .. .,._ ... _......... _ ....,.,...F .........._ _._..... .. .......
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
F
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 I Expiration Date
9.3 General Contractor
CC _. _....._, ._.,__... Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to re filled in by
Building Department
Lot Size __ .....::._ _m
Frontage _.....
Setbacks Front
SideL ...._ :.. R .... L f...:_ ,,:...,1 R ... ..,. .._, _..,_
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
arkin )
#of Parking Spaces --
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 DON-KNOW., 0... YES 0._.__.:
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
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
3
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 a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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 here.
Of Proposed Work:
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 ❑ 2B It ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ - __ — 3A ❑
I Institutional ❑ I-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.
r
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: 3 Proposed Use Group.
_w
Existing Hazard Index 780 CMR 34):_ w .,, .,,•„ r........._. _,.. 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 8I
1 st
2nd 2n d
.
_.,,. .. 3rd
3rd
4 h 4in
Total Area Tota{Pro osed New Construction(s
(s fl p _.n,._. _._.fl.........
_....,
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 E] On site disposal system❑
(( Versionl.7 Commercial Building Permit May 15,2000
1 Departure t use,only
BI,+din Department CurpsofPem�t+t
i of Northampton stat
�) ! g pb Cuf/Driveway Perrnrt
W4 12 Main Street SeW6r/Sept6Avajlabllltx
NOV
Room 100 WaterlWell AVallabillty
mpton, MA 01060 Two Sets ofStructuaC Plans
_- 6te-4 - 7-1240 Fax 413-587-1272 Pldf/Site-Plans
OtherSpecify
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
to 1 �`7 �t�;x St{• Map Lot Unit
Zone Overlay District
Elm St.'District
...... _...,.. t CBDistricf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
h� w
Name(Print) Current Mailing Address
Signature Telephone
2.2 Authorized Agent:
rz
Name(Print) Current Mailing Address:
_ ...
_.__._.. „_ .....__...w__. . ._......._ .. ._ .:
—k
Signature Telephone
SECTION 3`-ESTIMATED`CONSTRUGTION COSTS
Item Estimated Cost(Dollars)to be Official Use.Only:
completed by ermit applicant
1. Building (a)Building'Permit;Fee
2. Electrical ___.._'__ •._.•w. (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
This.Section-For Official Use Only
Building Permit Number Date
Issued
Signa e:
B Commissioner/nspector of Buildings Date
315 PLEASANT ST BP-2015-0515
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 142 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-2015-0515
Project# JS-2015-000979
Est. Cost: $17800.00
Fee: $106.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 12327.48 Owner: PAOUIN GERARD A C/O REAL ESTATE MANAGEMENT
Zoning: GB(77)/URC(23)/ Applicant: C PHILIP ANDRIKIDIS
AT. 315 PLEASANT ST
Applicant Address: Phone: Insurance:
52 Main Street (413) 585-9171
FLORENCEMA01062 ISSUED ON.111412014 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:
FeeType: Date Paid: Amount:
Building 11/4/2014 0:00:00 $106.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner