31A-069 (6) 206 ELM ST BP-2017-0057
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-069 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-2017-0057
Project# JS-2017-000107
Est.Cost: $19950.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 8058.60 Owner: SALLOOM SIMON
Zoning: URB(100)/ Applicant: C PHILIP ANDRIKIDIS
AT: 206 ELM ST
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
F L O R E N C E MAO 1062 ISSUED ON:7/1 9/2 01 6 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: OI: 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 7/19/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
1 Department use only
.JUL 14 20N City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
L._ 212 Main Street Sewer/Septic Availability
oar r�crons Room 100 WaterANell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Piot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 .SITE INFORMATION
1.1 Property Address: This section to be completed by office
«� C(m Sr Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY eWWIBn8HIP/AUTHORIZED AGENT
2.1 Owner of Record:
ShOicwOH 501400
Name(Print) Current Mailing Address:
5 �ll � ` Telephone
-VC 5-7-5 Svc
Signalise
2.2 Authorized Agent:
C . '�,I C' Arcfr r t k ek t; i.(o5 r2.-1/4
r 1�a4
Name(Print) Current Mailing Address/
s S -9t 7f
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /c7 95-0 (a)Building Penult Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6) �/
3. Plumbing Building Permit Fee "/ y0
4. Mechanical (HVAC)
5.Fire Protection ,/ �9 ry
6. Total=(1 +2+3+4+5) q�l � Check Number 7065 _
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: La � �/ 7—/7—Ar
Building Commissioner/Inspector of Buildings Date
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicablg)
New House ❑ Addition 0 Replacement Windows Akeration[s) ❑ Roofing ig
Or Doors ❑
Accessory Bldg. ❑ Demolition 0 New Signs [Cl Decks [Q Siding[C] Other[C]
Brief Description of Proposed
Work: 9-1'4, p(,rt-„ood S"o--51e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _ Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes ^No. Is construction within 100 yr. floodplain_ Yes_No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
I. Septic Tank, City Sewer_ Private well City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT' OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, WHO 4 110 nnpp/q r9/Utliy¢ Ay-et-774 as Owner of the subject
property /p, ,�
hereby auth 'ze C �tt 0 a4.rc&rt et c(rS
to act beef,in ali meters relative to wank authorized by this building permit application.
Signature of r Date
1, C .Ph d,l> A-tolrt('tcL. ,) 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.
C••1 Lt\,i, r-✓c,tr.AL t LLS
Print Name
743)lea
Signature of Owne Agent Date
City of Northampton 212 Main Street,Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, 854, 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: 2% E(vH
The debris will be transported by: Por e,., e 12Ac k -q
The debris will be received by: VcAt-7 J
Building permit number:
Name of Permit Applicant C i d,C' tA-c r, r, t(
7/r3//
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ;t Not Applicable ❑
Nemo of License Holder-. C.! - ') ,(D Arcr.(C.pct.15 —S- 07/1L7
License Number
f
Address Expiration Date
SG;''y. 7i,
Signature Telephone
9.Reoistered Home Improvement/� Contractor: Not Applicable 0
e ,Y �((,e rT.-e)"o, IC, a 13.2:6'i
Company Name Registration Number
/—f' T /t vi 2 `1/r7
Address Expiration Date
Telephone 5f'-' 9r71
SECTION 10-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 '4 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 10835.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building Permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code.City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
••
Department of Industrial Accidents
Office of Investigations
T --' I Congress Street,Suite 100
Boston,MA 02114-2017
- wwwmass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C 1.,, ;,o At ,<(y t k t ov( •
Address: "t
City/State/Zip: t TLT. _e-e_ MA- o ssThone#: - S-
Are you an employer?Check the appropriate box:
1.❑ I am a employer with
4. El am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
listed on the attached sheet. 7. ❑ Remodeling
2.�. I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
a ty comp.insurance.:
9. ❑ Building addition
(No workers' comp. insurance 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself [No workers' right of exemption per MGL
Y comp. 12.IrAIRoof repairs
insurance required.]' C. 152, 61(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant hat checks box tl I 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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employrets.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. [52 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 DR for insurance coverage verification.
I do hereby certify under the pain rt enaINes of perjury that the information provided above is true and correct.
Si•nature: Date: 7 6
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):
I.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: