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25C-139 (12) 173 NORTH ST BP-2019-1487 GIs 4: COMMONWEALTH OF MASSACHUSETTS Mao:Block:25C- 139 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 a BP-2019-1487 Project H JS-2019-002411 Est.Cost:517000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: C PHILIP ANDRIKIDIS 071107 Lot Siu(sg. R.): 30709.80 Owner., CZELUSNIAK ROBERT F&ABBIE Zonine: URB000 Applicant: C PHILIP ANDRIKIDIS AT: 173 NORTH ST AanlicantAddress: Phase. Insurance: 52 MAIN ST (413) 585-9171 FLORENCEMA01062 ISSUED ON.612612019 0.00.00 TO PERFORM THE FOLLOWING WORK:ST RI P & 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 it 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 Signature: FeeType: Date Paid: Amount: Building 62620190:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner -- -- Versionl.7 Commercial Building Permit May 15.2000 if 1ECEIVED Department use only C Ly of Northampton Status of Permit. Building Department Curb Cut/Drmeway Permit JUN 2 5 2019 212 Main Street SewenSeptic Availability Room 100 WaterM/ell Availability DEPT OF null DING INSPECTIONNo ampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON.fuphooB 4413- 87-1240 Fax 413587-1272 Plot/Site Plans Other 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 BPP,/% '/z/ 1.1 Property Address'. cThis section to be completed by office (7'j r�uv S4_. Map ,p5r l Ci Lot / 3 / Unit Zone Overlay District -- Elm SL District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of R rd: X77 �u2i? fi Name(Pn Current Mailing Address: ;1 to� & /%— /'2-, N Signature Telephone Ll 2.2 Authorized Anent: �h.I.P A rArtk,v�,s YVr a7n,' itt- ( Name(Pnnp Cunent Mailing AJdress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed oy pennilt applicant 1. Building t-7 C700 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fw 4. Mechanical(HVAC) 5. Fire Protection 6. Total Fill +2+3+4+5) Check Number d3 This Section For Official Use Only Building Permit Number Data Issued Signature: 4 - 25 2oiy Buildwg missiaraallmpector of Buildings, Date Versionl.7 Commercial Building Permit May 15,2000. SECTION4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑_Rooflnj9L-Change of Use Other❑ Brief Description Enter a brief description here. Of Proposed Work: t SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Cheek as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 11A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ is ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Fadory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ 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 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1'r 10 2' 2" 3`° 3`° 4 t 4m Total Area(so Total Proposed New Construction (so Total Height(8) Total Height it 7.Water Supply(M.G.L.e.40,§54) 7.1 Flood Zona Information: 7.3 Sewage Disposal System: Public 0 Private 0 Zone Outside Flood Zone[] Municipal 0 On site disposal system❑ Versiont.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Depmeu nd Lot Size Frontatse Setbacks Front L: R: 1.: R ._. _. Rear Building Height Bldg.Square Footage Open Space Footage 0.ur mw mime bwg&paved N ofParking Spaces Fill: volume&Locgnw A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document H B. Does the site contain a brook, body of water or wettands? NO O DONT KNOW O 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,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. t Version L7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Arai Not Applicable ❑ Name(Registran0. Registration Number Address Expiation Data Signature Telephone 9.2 Registered Professional Enginear(s): Name Area of Responsibility Address Registration Number Signature Telephone 6piation Dale Name Area of Responsibility Address Registration Number Signature - Tekphane Expiration Date Name Area of Resparsibility, Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiation Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone f ^ Versiiai Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER RENEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 .OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J:ly CZ e l"I"'W ii as Owner of the subject property 1 ,u V hereby authorize � L `Ian A ""�- ` � to act on my behalf II matters relative to work authonzed by this building permit application. G Azs Signature of Dale I. .. '�'`•�y F� .f.fit-.t<.} __ .as Owner/Authonzed 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 pequry Pri Nam b�v*�s Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: /1 �` Not Applicable ❑ Name of License Halder C 'up1"51.x, rtvs Y try cL`� C7, 7 ii License Number Address Expirakon Date »S^4f 7/ Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§251 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 ilding permit. Signed Affidavit Attached Yes No O f 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 150A. Address of the work: 1?37,3 The debris will be transported by: The debris will be received by: �"(t::tj Building permit number: Name of Permit Applicant 21.69 Date Signature of Permit Applicant The Common wealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Wiliarkers'Compensation Insurance Affidavit:Builders/Contractors/Elecuicians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information (p /� Please Print Legibly Name(Business/Orgmizaliomindividua0: 1 �.cp A J,-akae.{ is Address: City/State/Zip: r1cw-^Lax ru.L Phone M T ---P,7� Are you as employert Cheek the aparoprieste boa: Type of project(required): I...,.�....iirntt{l am a employer with ample ocs(Nil and/or put-twel' 7. ❑New construction 20[ a a sole ptopriennor pamrership and have no employees working fn-anin 8. []Remodeling Fes' y capacity.INo works%comp.announce required.] 3.❑1 am a hmneowner doing all wink myxlf.[No workers comp.insurance regwred,]' 9. ❑Demolition 4 1 am a bmrrcowner and will be,hating wnmctors w conduct all work on my pmperrs, Iwill 10❑Building addition arsare Nu all nonwaemrs ntha have tondos'nnmpenweon inxamnamare sok 11.❑Electrical repairs or additions pmpraturs with Im anpinyea. 12.❑Plumbing repairs or additions 50 l am a gonna!contractor and I have hoed the sub-contractors listed on the swathed sheet. 1 OOf repairs These sub<onvacturs have employees and have wmkets'compsumnc ioe 6❑We are a corporation and its officers have exercised thee tight i fexap nroper n MGL c. 14. 152,§I(0),and we have no employees.[No workers'comp.aauranw requited] 'Any applicant that checks box#I must also fill out the section below showing thea workers'compensation policy insinuation. Homeowners who submit this affidavit indicating they are doing all work and then hire outs de contractors most submit a new affidavit indicating such. IConoemms Nm check Nis box must attached an additional seen shewmg Ne name ofde sub-wnhanon and since whether.runt Nnae entities have eouldloyees. nine sub-contractors have employees,they must provide their wotkets'rump.policy mmober. J am an employer that is providing workers'compensation insurance for my employees. Below is fie policy andjob 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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.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 rhe pains and penahtes ofperjury that the information provided above is aue and correct Signature: 1532� Date: LY 7/t(Q/0 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermiNLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 7.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persom Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shal I not because of such employment be deemed to be an employer." MGL chapter 152,425C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,p25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)motels),addresses)and phone number(s)along with their cenificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alm be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permiulicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided m the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia