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24D-280 (2) 165 CRESCENT ST BP-2018-1289 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block:24D-280 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory-ROOF BUILDING PERMIT Permit BP-2018-1289 Proiect# JS-2018-002293 Est.Cost: $24000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: C PHILIP ANDRIKIDIS 071107 Lot Size(sg ft.): 13808.52 Owner: LEVY BENJAMIN Zonine: URB(100)/ Applicant C PHILIP ANDRIKIDIS AT. 165 CRESCENT ST Applicant Address: Phone: Insurance: 405 RYAN RD (413) 585-9171 FLORENCEMA01062 ISSUED ON.6/512018 0.00:00 TO PERFORM THE FOLLOWING WORKSTRIP & 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 Sie tore• FeeType: Date Paid: Amount: Building 6/5/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of North nri JUN BO&I419ep rtrnE nt 212 Main reel 0 DEPT OF O� 060 one 413-b;37-7707753x-4 3-587-1272 Q LP =77� APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office IU5 (irt<'t mi "�ra'4 Map Lot -)'10 Unit — 1�Of 4�0-vwp�m 1 0 A 01060 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Lny -1.4 Name(Print) P.;, �tneef A0,T c6 Gunmnt Mailing Addhass: Telephone gnature 2.2 Authorized Agent: C.C. Philip Piis Obsqtf eviu M Name Current Mailing Acidness: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be Official Use Only completed by Re mit applicant 1. Building Do 0 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 040 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2 13+4 15) 1000 Check Number I This Section For Official Use Only Date Building Permit Num Issued: Signe— lz -- -A Buildi�40 ninnissionedinswchor of Buildings Date Nirnceroo Coni EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 1 Frontage -- ___ Setbacks Front Side L: R: L:1 R:= Rear Building Height Bld g quare S Footage / g Open Space Footage (-- % (Lot area minus bldg&paved parking) 4 of]"arking Spaces Fill ) _ volume&Local on) -- ---" A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES 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 k�-__ B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: __] C. Do any signs exist on the property? YES O NO O 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 IF YES, describe size, type and location: I _ E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Roofing Ef Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[o] Other[E:0 Brief Description of Proposed Work: J[ t ] O.V1 G1 �Q51'1(Na.A IL Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.tE New houseand of addition to,existinn housing, oomolote the following: a. Use of building : One Famili Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? J. 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 CitySewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 3e'1�Gnn.n as Owner of the subject property hereby authorize to act on my behalf all matters relative to work authorized by this building permit ap Iic tion. 6SIK ig alum 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. C �1��1 Print Name a O Signature of OwnerlAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: p11Not Applicable 11 NameLicense Holl vt Ort I I V License umber ��S R�iav� IbYe�ncP M � bl�l�2 2U �OIq Atltlre/ss/�' r,�J-�0 2 c-X�,Ir�\-`.� 11Expiratio Date Signature Telephone 4."Regitillerild HOMr OGlit!lY' Not Applicable ❑ INC. I � to l3 Company Name L Regisration umber �1 I Address Expiration Date Telephone I3 A) 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 Ves....... No...... ❑ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 If www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information p Please Print Leeibly Business/Organizatijjoo�nName: C . l��\VA 9\y\�V�� � iS Address:��� ` � City/State/Zip: �I P A(4 CI M0I0t Phone#: � � � a Pb I Are you an employer?Cbeck the appropriate box: Business Type(required): L❑ I am a employer with employees(fall and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurmtBar/Eating Establishment 2.p� I am a sole proprietor or partnership and have no y, ❑Office and/or Sales(incl.real estate,auto,etc.) / employees working for me in any capacity. [No workers'comp.insurance required] g. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]' 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other 'Any applicant dust checks box 41 nous,also fill out the section below showing their worke,s'compeosetioo policy ielorroalion. "If the corporate officers have exempled floorsl.,hot the corporation has other employees,a workers'cotnpens rtion policy is required and such an organization should check box el. I am an employer that is providing workers'compensation insurance for my employees. Below is Me policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lia# Expiration Date: 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 for ins;2=2 coven a verification. Ido hereby ¢reify,un er the pains a d pe hies of perjury that the information provided b o/ve is true and correct Sienature —n /�/� (��� Date' Phone# � 9l ;) " ODU Offwia/use only. Do not write in this area,m be completed by city or town gffixiaL City or Town: Permit/IAcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/To"Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: City of Northampton Massachusetts JI. DEPAR1tRiT OF BDILDZNG IRSPECTIORS Olt Rein St et a cipel Building Lrtnamptnn, MA 01060 SYry `�o Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: 1 (0 ca s CP Vif 4 (ease print house number and street name) Is to be disposed of at: (Pte se print name and location f cilfty) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant lar Owner Date If,for any reason, the debris will not be disposed of as indicated,the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed.