25C-199 (3) i
53 NORTH ST BP-2016-1213
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 199 (CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catep,ory: ROOF BUILDING PERMIT
Permit# BP-2016-1213
Project# JS-2016-002088
Est. Cost: $20000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq. ft.): 8537.76 Owner: TYMOCZKO 1ULIANNA
Zoninv: URC(100)/ Applicant: C PHILIP ANDRIKIDIS
AT. 53 NORTH ST
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
FLORENCEMA01062 ISSUED ON:4/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP, PLY & 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 CITE' OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/19/2016 0:00:00 $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 Permit:
Building Department Curb Cut/Driveway Permit
APR 1 52016 1 212 Main Street SewertSepticAvailability
' Room 100 WairtWell Availability
Northampton, MA 01060
Two Sets of Structural Piens'
phone'413-587-1240 Fax 413-587-1272 PlottSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
t Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
L. T.� til Mh /M }tM
Name(P nt) Current Mailin Address:
Telephone
Sign ture
2.2 Authorized Anent:
Name(Print) Current Mailing Address:
L41
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z (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
6. Total=(1 +2+3+4+5) Check Number
This Section For ficial Use Only
Building Permit Number: Date
Issued:
Signature: y
Building Commissioner/Inspector of Buildings
Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all appli0able)
New House ❑ Addition ❑ Replacement'Windows Alteration(s) ❑ Roofing
Or Doors l
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [M Siding[0] Other[a
Brief Descrytion of Proposed
Work: } ✓+ P r�C.i..x�c�. 5�.,,a�
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 existina 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 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. �- 2- L-C3 as Owner of the subject
property
hereby authorize
to act o my behalf, in all matters re tive to work authorized by this building permit application.
; 1
Signatu e f Owner Date
I, , P�` I`p p°'`J✓ k as Owner/Authorized
Agent hereby declare that fhe 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.
/I
Print Name
(6
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable !
Name of License Holder: .l 1/�,`c p n t tC . �� O'?t<O 7
Li ber
AA
Address Expir n Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable !
/ �oG 3
Company Name Registration Number
Address
Expiration Datfe
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 ..:: ! No...... !
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) 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 108.3.51.
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 IndustrialAccidents
r Office of In►►estigations
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 Leizibly
Name (Business/Organization/Individual): c_�c<<P X�diJc, os
Address: C40S-
City/State/Zip: ]Phone#: Lftl 7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
2V I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. E] Demolition
working for me in any capacity. employees and have workers' 9. E] Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
1❑ I am a homeowner doing all work officers have exercised their i L❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.�Roof repairs
insurance required.] t c. 152, §1(4) and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#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 sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workars'comp.policy number.
I am an employer that is providing workers'compensation insu rtancefor 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. 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 an penalties of perjury that the information provided/Jabove is true and correct.
Si nature: Date:
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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: