31B-135 (2) 33 TRUMBULL RD BP-2017-0593
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31B- 135 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-2017-0593
Project# JS-2017-000960
Est.Cost:$18500.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 071107
Lot Size(sq.ft.): 4530.24 Owner: PAPANTONES STAMO
Zoning: URC(1oO)/ Applicant: C PHILIP ANDRIKIDIS
AT: 33 TRUMBULL RD
Applicant Address: Phone: Insurance:
405 RYAN RD (413) 585-9171
FLORENCEMA01062 ISSUED ON:10/28/2016 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 10/2820160:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
- - City of Northampton Status of Permit
j_. Building Department Curb CWDriveway Permit
'I Z t i 212 Main Street Sewer/Septic Availability
I Room 100 Water/Well AvailabilityNorthampton, MA 01060 Two Sets of Structural Plans
z `� __:phone413-687-1240 Fax 413-587-1272 Plot/Ste Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6P- 17- 61 )
1.1 propene Address: This section to be completed by office
Map Lot Unit
3 3 i,-,,,.,t„1 t i= e1
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
t-1 Owne//r�of Record:
/ ?r ft7ditc 33 71—,e(k
•
Name(Enna Current Mating Address:
5G et 7 — 76 — s--dYs
/.n✓?rA.r ///�✓"_
J' Telephone
Signature
2.2 Authorized Agent:
C .n,dP Arcft ,-tk-b1r4 YGs t r . _.
Name(Pnnt) Current Mailing Addres
C „---2 5`C5"-tf/f
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COST
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r. dsC-O (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 ,y J}
6.TTotal=(1 +2+3+4+5) Check Number C�+ a f/ 4Y(/
This Section for Official Use Only
Building Permit Number: Date
issued:
�Buil�t �
/d - 721i
t ng Cioner/Inspector of Buildings
GGT 27
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Arklition 0 Replacement Windows Aiteration(s) j] Roofing yg
Or Doors G7
Accessory Bldg. 0 Demolition 0 New Signs [0] Decks ICJ Siding[CH Other[CQ
Brief Description of Proposed
Wort -.
Work 5 i es.n,,f SA ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. 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 treating? 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 SewerPrivate well City water Supply,_,_,
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORjAPPUES FOR BUILDING PERMIT
�✓ '"y �
I, � /1—re/fr ,as Owner of the subject
property '� �1
hereby authorize C t` ht1 (] AnoU 't t-t a rS
to act on my behalf,in all matters relative to work authorized by this building permit application.
S nature of Owner �" Date 11
C .C�t*i.�> `�r otv-,y.GL-) , as Owner/Authorized
Agent hereby deUare 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.
-T%-hk,t> f lT t
Print Name
../" /(1711(L Iib'
Signature of Owns Agent Date
City of Northampton 212 Main Street, Nonhampton, 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:
The debris will be transported by: Per ey.c e -5
The debris will be received by: Jcdl—r t2-i,,cl,
Building permit number:
Name of Permit Applicant C•i?-1d,C' A-6 r, t( c
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (� Not Applicable ❑
VName of License Holder: C., \ ,() Alett,l.k..CtiS CS- C7/yz;7
License Number
(-f o 3 II-y..-, Z -/i )---(---L.rt ec MAA 6//2-71 / 7
Address Expiration Date t
—� SfJS 'J' 7 j
Signature �- Telephone
9.Registered Home Improvement Contractor: Not Applicable CIC , it.p iA,—d'c-rtc , a rs I al Z., t--f .T,
Company Name Registration Number
Z-t(< R y t:-.< 1)- ,A Litt 7/t 7
Address Expiration Date
Telephone SES T 7/
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 121 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 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,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,von 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 tM assa£h u_sens
Department o:'industrial Accidents
Office o%'investigations
_ Congress Street, Suite IPG
Boston, iri4 02114-2017
wwzv.inass-govidia
Workers'Compensation inslraIlce Affidavit: Builtsere's/Contracts;sfEtectr e-,anerP h tubers
Applieant information Please Print ' eQibi-
Name (BusinessiOrganizationfindividuall:
Address:
CitydState/Zip: _ - "' ='Phone=: --�, ee-
- _
r".re you an employer?Check the appropriate box: 11 Type niprn ee:(required):
1.0 tam a with employer 4. Q I am a general contractor and
p —.. ( G. 0 Nev:CnnStrtlCt1011
employees(Mi ami/or part-time)." have hired the sub-contractors
2.01 ; am a sole proprietor or partner-
ship
listed on the attached sheet. +. Q Remodeiin
ship and have no employees These sub-contractors have g_ Q Demolition
working for me in any capacity. employees and have worker
9. ,-_
Building addition
workers' cont comp.insurance:
o (I
p insurance
5. corporation and its 10.0 'Electrical repairs or additions
required.] ❑ We areea
7.LJ I am a homeowner doing all work officers have exercised their 11 11.0 Plmnbing repairs or additions
myself" right ofexempcion per MGL
[No wvoli:ers' comp. i i2.r Roof repairs
insurance required_}' c_ 152,eI(d),and we have no
employee=_. (No workers' 1=.Q Other
comp. insurance required]
'Any applicant hat cheek Nom n I mus also fill out this section below shoes s their wtvrk urs compensation unlink infom,nuon.
tionttm,nars Mite'submit this affidavit indicatn_dray the donne all work and then liirz onside contractors must submit a new affidavit indicatingsah.
:Contractors that check this box must attached an additional sham showbiz the name of the s!6-coanauoes and slat.thua,er or not those motes hope
employees. lithe sob-coniraflnrs haveemnlopees-they must provide their workers"comp.011iiCy numbL:r
I am nit employer that is providing workers'compensation insurance for n{r employees. Below is the puller and job site
information.
Insurance Company Name:
Policy#or Self-ins. tic.=:.,, -spiration Date:,
Job Site Address:_ . Citys/State;Zip:_
Attach a copy of thewor key compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MG4 c. 152 can head to the imposition of criminal penalties oft
rine up to SI,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 5250.00 a day against the violator. Be advised that a copy of this statement may be Forwarded to the Office of
investigations ofthe WA For insurance coverage verification.
do herein,cent,t,rtrrter the patns.nrn(j3ennities of perjury that the Won
nntton provided above is true and correct
Signature: Date: /Piz i /6
Rhone g: T t S ` 9/7I
Official ase 011 v. Do not write in this area,to be completed or city or town official.
City or Town: —Permit/D;cense#
issuing AIM:Mitt(circle one):
:. Board of Health 2.Building Depai intent 3.City/ own Clerk 4.Electrical inspector S. Plumbing inspector
G Other
Contact Person:��, Phone#: