23D-021 (3) 504-505 ELM sr BP-2017-1062
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-021 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 4 BP-2017-1062
Project# JS-2017-001820
Est.Cost: $10750.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 7013.16 Owner: TRAVERS DAVID.'& KAREN ROY
Zoning: URBn001/WP(17)/ Applicant: C PHILIP ANDRIKIDIS
AT: 504 - 506 ELM ST
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
F LORENCEMA01062 ISSUED ON:3/24/2017 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 Sienature:
FeeType: Date Paid: Amount:
Building 3/24/2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240. Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
0p0,k
Department use only
City of Northampton Status of Permit
` Building Department Curb Cut/Driveway Permit
`1..%1 212 Main Street Sewer/Septic Availability
'1 . t.—- Room 100 Water/We1 Availability
\\\ "Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PlovSite Plans
Other Specify
'"'APPLICATION TO CONSTRUCT,ALTER,REPAIR,,,,/RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6 p-17.- 100-i
1.1 Property Address: This section to be completed by office
X94 -5u6 t7- len Map Lot Unit
Zone Overlay District
Elm St District CB District_,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Own°(of Record: ��
X OA/AD `r;ei i( iz'2c' 2 3 /7l<--// ST----
aeme(Pm) Cwvent Mag Address:• 41/3 370 —7r/ -
A Telephone
Signature
2.2 Authorized Aoent:
C.ti,,t p ArtA • tV--ek 4 'tt.s rlvc n tit
Name(Pont) Cunent Mailing Address/
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item i Estimated Cost(Dollars)to be Official Use Only
' completed by permit applicant
1. Building /07 S-v (a)Building Permit Fee
a Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection /��/ 117!/
6. Total=(1 +2+3+4+5) Check Number // t/7
This Section For Official Use Only
Date
Building Permit Number':: - issued:
Signature. <" '. 3 -ay-/7
Building Commissioner/inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail anoiieabie)
New House [] Addition D Replacement Windows Alteration(s) ❑ Roofing S
Or Doors ❑
Accessory Bldg. n Demolition 0 New Signs i❑] Decks (C Siding[p] Other[Cl
Brief Description of Proposed
Work: S}r.c c.-.1.--cl. <AA trksIK
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. 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 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 H.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 T City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
SI I, //��/�- „1 V£ l✓ /St�l� P as Owner of the subject
props ri
hereby authorize C + A. (`I' .134trr t+it, _
to act on my behalf,in
allll afters relative to work authorized by this building permit application.
Signature of Uwr r Date Lq /
I, C ,F n*(,i^ AnoLr E d.,, ) . 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.
CTt1.t,ia A✓C1'r.X iatS
Print Name -p
Signature of OwnefAgent Date
II
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:lI1� I II � Not Applicable ❑
Name of License Holder: C , Pk,�r(\ /t�r f Kic4 r ` 0 7 //O'7
h / 'f� License Number
LjC'� .-. Ii- .A \ (Wein(-Le (—ll L'�f l7
Address YY Expiration Date
Cr::: --7_...,- ------Th' f Bc— cll l/
Signature Telephone
Einar'/'
9.Registered Home lmnresrement Contractor: , -:i_ Not Applicable 0
r�oio-7 3
Company Name Registration Number
Address Expiration Date
Telephone
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 }SLlNo ❑
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 108.3.5.1.
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,duringand 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 tlr State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apoljgable)
New House ❑ Addition (l Replacement Windows Alteration(s) f Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (p] Decks [❑ Siding En] Other(0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
ea. if New house and or addition toexistinq housing;complete tlip foilowinSl:
a. Use of building :One Family Two Family Other
h. 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
,as Owner of the subject
property
hereby authorizeto act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Print Name
Signature et Owner/Agent Date
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: ° t ' S oir C I H
The debris will be transported by: I-lorc
The debris will be received by: *AL/ 1 ,I,C(t-5
Building permit number:
Name of Permit Applicant C,Pntl,C' t� �.t . r., zI ,)
31 .2-0,I11
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
wwwrnass.govldia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Anpiicant Information Please Print Legibly
Name (Business/Organization/Individual): �- rr. (^,, ,tet
Address: ,i':,� !2y_,-.
City/State/Zip: ,t'"t "a C i ., i„z:"Phone#: td-21. „ ';r
E Are you an employer?Check the appropriate box:
4. I am a general contractor and 1 Type of project(required):
I. I am a employer with 6. ❑New construction
employees(MI and'or part-time). have hired the sub-contractors
7..0 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- ❑ Demolition
working for me in any capacity. employees and have workers
. insurance.+ 9. 0 Building addition
coo
]No workers' comp. insurance P
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself o workers' comp. right of exemption per MvMGL 2.
y p c. 153, §1(A),and we have no l Roof repairs
insurance required.]; 13._i Other`
employees. [No workers
comp. insurance required.]
x Any applicant that checks box 41 must also till out the section below showing their workers compensation policy iafom,aion.
Homeowners who submit this affidavit indication they are doing ail work and then bin outside contractors must submit a nett'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 hose entities have
employees. if the sub-contractors have employees.they must provide their workers'comp.policy number.
7 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.a: 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 tread 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 S25Q_00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby eertiffr under the ppmns. jiettatties of perjury that the information prodded above is true and correct.
Siknature:
Phone if: ct7- 9/9/
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License# _ II
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 0: