42-044 (6) 661 WTSTH.AMPTON RD BP-2017-0521
GIS;:: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-044 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-2017-0521
Project# JS-2017-000852
Est.Cost:$8650.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 25047.00 Owner: O'BRIEN MICHAEL 1&GAIL L
Zoning: Applicant: C PHILIP ANDRIKIDIS
AT: 661 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
FLORENC EMA01062 ISSUED ON:10/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ENTIRE ROOF - 26 SQRS
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 Occu.anc si!nature:
FeeTvpe: Date Paid: Amount: •
•
Building 10/1920160:00:00 $40.00
212 Main Street,Phone(413)587-1240. Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
. _ City of Northampton Status of Perms.
-,\ Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
''
L r & ,,.,__, Room 100 WaterPHell Availability
JNorthampton, MA 01080 Two Sets of Structural Plans
- ----, „ phon 413-587-1240 Fax 413.587.1272 Plot/See Plans
Specify
..;~r OtherSpecifyAPPLICATtON CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I SECTION 1.SITE INFORMATION
1.1 Property Address: This section to be completer)by office
(- bt wes4-1"=..+,,ph.n. R34 Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: y� �--
X Name Pont)4er Q�j2 A-4rr_dJ '6/ &dwr. `t/efMfro� /-Ytbwt .j '
Conant Address:
L.CL ca o:Sisv I Telephone �..
Signature C/
2.2 Authorized Anent
C - ,( P r -c'A ,- ( le..A Ycs 2tltir tacit
Name tenni) Current Mailing Address(
2.2--Th-----' 7 S£#,S--9f it __-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. Building p,6SQ (a)Budding Permit Fee
o
2. Etectrical (b)Estimated Total Cost of
Construction from(e)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
8.Fire Protection -
� 3'
B. Total=(1 +2+3+4+5) 4/14,.
_
_ Check Number /"'t' 1 y {,)
This Section For Official Use Only
Building Perrntt Number: _ Date
� ,��// _ Issued
Signature: -- /ri i /d—/F'L6
Building Commissiwrernnapector at Buildings Date
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition 0 Replacement Windows Alteration(s) Roofing aligi
Or Doors ❑
Accessory Bldg, d Demolition ❑ New Signs 4077 Decks (C] Siding(C) Other ffl
Brief Description of Proppss�ssd „ ,e
Work: ('N`r'.14) .x.. ....h vent, sC' — Fit s^tic ' ,59a.1jl✓�f i oG(.
Alteration of existing bedroom Yes No Adding new bedroom (/ _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
Sa.If New house and or addition to existing housing,complete the folioed g;
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 stories?
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
1K, I, . (CM•AtTs ,Qtiers ,as Owner of the subject
/ Property s� r(�> Ant(hereby authorize +` h.t rct.rt kaiS
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of owner Date
C . t(,n Anoty t[- .ct..} ,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.-Tk , Ai'Jr.(tcliS
Pant Name � i
r- = 1°fry
Signalum of Owne Agent Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name ofUcenSe Hader: G:Psntk,OCS_ \--%int7
License Number
�0 ,� etgt ,A � � / 7
Address Expiration Date
MS 3' 71
Signature ---^"' Telephone
¢,Registered Home Improvement Contractor. Not Applicable ❑
C ;nett, r"F r-c7;, �C td l ft..t,"7
Company Name Registration Number
L-em; ley t:.-- 2 -A `z
Address Expiration D a
Telephone 5-E 9( 7/
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.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_y
Signed Affidavit Attadted Yes / No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Owellimts 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
Ss supervisor.CMR 788, Sixth Edition Section 108.34.1.
Definition of Homeowner:Person is)who own a parcel of land on which hetshe 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
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: (( � 'e SL ! o rt,(
The debris will be transported by: Po erce I ( ; 9
The debris will be received by: vc1 -y CZ �yclu J
Building permit number:
Name of Permit Applicant C ,1.c 44,6 ir r,
D ! !!
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
_ _-- Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BosincssiOrganiratioMndividuap: '^
Address: "`iCity/State/Zip: r - e -r CPhone 4:
Are you an emptoyer?Cheek the appropriate box: Type of project(required):
L 0 I am a employer with 4. 0 t am a general contractor and I 6. 0 New construction
employees(full andfor 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 g. 0 Demolition
working for me in any capacity. employees and have workers
P 4. 0 Building addition
(No workers' comp. insurance comp.insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. (No workers' comp. rishi of exemption per MGL 120Roofrepairs
insurance required]t e_ 152.§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
`Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Homemmers who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new alfida%it indicating such.
:Contractors that cheek this box must attached ark 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 worker comp.policy number.
I am an employer that is providing workers'compensation insurance for nm employees. Below is the policy and job site
information.
Insurance Company Name:,`
Policy n or Self-ins. Lie. r: Expiration Date:_,,,
lob 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.
f ao1hereby eertii, 'ttii thtlte pcenalties of perjury that the information Datrovi d above is true and correct.
b ____
Phone if:
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#: