25C-139 (9) 173 NORTH ST-CZELUSNIAK BP-2017-0489
ti.u: COMMONWEALTH OF MASSACHUSETTS
MapGlock:25C- 139 CITY OF NORTHAMPTON
LLS-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-2017-0489
Project# JS-2017-000808
Est. Cost: $6775.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Coml.Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(so. ti.): 30709.80 Owner: CZELUSNIAK ROBERT F&ABBIE
Zoning: URB(IQPY Applicant: C PHILIP ANDRIKIDIS
AT: 173 NORTH ST - CZELUSNIAK
Applicant Address: Phone: Insurance:
408 RYAN RD (413) 585-9171
FLORENCEMA01062 ISSUED ONi10/13/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP FLAT ROOF, INSTALL NEW ROOF,
REPAIR SIDING
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: Houser/ Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: ii: 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 10/13/2016 0:00:00 5100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Version I.7 Commercial Building Permit May IS,2000
OepartmeM use only
City of Northampton Status of Permit
Building Department Cub'GutiOri Remit
4 ZQ S 212 Main Street Sewer/Se(AcAvaaabMy
Room 100 WeflVYell Avaikbigty
Northam
ett SettofSeuctorstffiens
�, "a ons one 413-587-1240on, MA 01060 T
Fax 413-587-1272 Pbvsae Plans
Ogler Specify
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,PruDertv Address: This section to be completed by office
(`t%-r- 1 j1-, Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4-2" e'c(o� rC 1/4
J7s tie. / h%N ;. ,dAp7, 6.0 4,0
Name(Pum) Current Mailing Address:
'-33) SF,' 3S7S
Signature Telephone
21 Authorized Agent:
. .t. r 4ndset ILA tS Lees-
Name
a;Name(Pani) Current Mailing Address
Tj Ss "',' 7/
Signature fi.� -__ Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS ^�
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Budding b.7 75,. (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6) _^
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection /� 7�
6. Total=(1 +2+3+4+5) Check Number Lii6.9 /Q{/
This Section For Official Use Only
Building Permit Number Date
j/may Issued �+r y�R
Signatu '- e
�.5�/ �tLUI�I�C,-V
Bulking Commissi.-.r Spector of Buildings Date OCT r r 201-6-\
DFYi Cr Bu rc?IONS
r,�n. rz arena
Version)-7 Commercial Building Permit May 15,2000
SECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC tett OF ENCLOSED SPACE
interior Alterations 0 Existing Wall Signs 0 Demolition❑ Repairs Additions ❑ Accessory Building
Exterior Alteration 0 Existing Ground Sign❑ New Signs Roofing IF Change of Use Other
Brief Description t'1. _ �.a
Of Proposed Work: r Y 4 Tt•'4`®-S�41 rt(x-.r Si"-'
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Al 0 A-2 0 A-3 0 IA 0
A4 0 A-5 0 1B I 0
B Business ❑ 2A 0
E Educational ❑ 2B ❑
F Factory ❑ F-I 0 F-2 0 2C 0
H High Hazard ❑ 3A 0
I Institutional 0 I-1 0 I-2 0 1-3 0 36 0
M Mercantile ❑ 4 0
R Residential 0 R-1 0 R-2 ❑ R-3 0 5A 0
S Storage ❑ S-1 0 S-2 0 58 0
U Utility ❑ Specify:
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; Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 760 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1s n
3rd
4th 4n
Total Area(st) Total Proposed New Construction(sr)
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 0 Pdvate 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
Version1_7 Commereiat Building Permit May 15,2000
a. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: it L: R
Rear
Building Height
Bldg.Square Footage
Open Space Footage ^in
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 0 DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and Location:
E. W II the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over I acre? YES O NO 0
IF' YES,then a Northampton Storm Water Management Permit from the OPW is required.
Versiont.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION 11 OWNER AUTHORIZATION-TO BE COMPLETED WHEN
``// OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/� I, 7I-X C 2/e 4.4,47p4 ..nA as Owner of the subject properly
hereby authorize C -Ph•1.4e Av-cArtIC,cl+3 to
act on my behalf, all matte
relative to work authorized by this building permit application. /
Signature of er Date
?t,tttr, , 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 paines of perjury.
Pont Name -� --
(O(o/fE
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor; 7r Not Applicable ❑
Name ofLicens.Hoider: e -�i '14p Are)rt.It. Ll v K2- f.7 .
License Num
Kc'S 0 _ Z of h l+a—e.-t +-Ap It
Address Expiration Date
--(`y s' sr-9r -71
Signatr� Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.152,§25C(8))
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 tLY No Q �,
Version I.7 Commercial Building Permit May 15, 2000
_
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 789 CMR lie(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable Q
Name(Registrant)
Registration Number
Address
Expiration Date
Stature Telephone
9.2 Registered Professional Engineer(s):
Name _,___,--� Area of Responsibility
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
Name Area of Responsibility
Address __ Registration Number
Signature Telephone Expiation Date
9.3 General Contractor .-- ~ ..
C \fit"krQ FVCkr ,Ltt`t _._. Not AppticableQ
Company Name:
cel u.--.tin pct (Z..uc—)
T
Responsible In Charge of Canstmdion
l" ¢.t t.� {Z et-
Address
Signature — Telephone
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 150k
Address of the work: l
The debris will be transported by: . J
The debris will be received by: v/a(rte.x fie-s--re
Building permit number:
Name of Permit Applicant CSN-i.,0 A—c)
icier
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
: 13� Office of investigations
' I Congress Street,Suite 100
- _ Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
;y
(Name(Business/OrganizatioN _
lndividual) C K'k,.tfQ 4.,„jyt(C..,ckj
Address: Linc' f& . re d
City/State/Zip: (re.... G, - Phone#: CQ. ' 't 1 (
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and I 6. 0 New construction
employees(full and/or part-time).' have hired the sub-contractors
2.14 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
working for me in any capacity. employees and have workers' 9 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. right of exemption per MGL l?�{goof repairs
insurance required]t c. 152,§1(4),and we have no ,, E]
employees. [No workers' 13.0 Other
comp.insurance required.] i
`Any applicant that checks box#1 mint also felt out the section below showing their workers'compensation pricy information.
}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. lithe 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.Lie. L . 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 MGI.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 certifyunder—imthe pa sties of perjury that the information provided above is t
true and correct.
nature: �, `-�
SS ._... Date: /01r.- it c
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#-- _,T
' 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 ti: