25C-160 (5) 4�ttAMP2O
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�IASEAClfttSf ttE
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CONMENSATTON INSURANCE AFFIDAVIT
(li censee/perini tiee}
with a principal place of businessJresidence at:
�.- 6- ylpm -/iv. (phone#) 60L-
(strceVcity staielnp)
do hereby certify, under the pains and penalties of peg3ury, that
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expimdon Date)
(Name of Contractor) (Insurance Company/Policy Number) (E-\piradon Date)
(Name of Contractor) (Insuance Company/Policy Number) (ExTimtion Date)
(anAch additionl sbect ifneo=ss to mchidc mforrnarioo pertaining to nll ova rndora)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homcowrxn who employ per om to do ii iate,.„ce,0=3tr=oo or repair wade on s dwelling of
not more than three units in which the borneowncr resides or on the grounds apprutanaoi tlxrcto aR not grncrnlly ooasidcrcd to lx
employers under the wotica'a oomp=atioa Act(GL152,=1(5)�application by a homeowner for a hecase or permi may evidcnoe the
legal ctzaiu of an employer under the Worker's Compomsiion AcL
I undersund this a oopy of this r alemrat may be forwarded to the Dtpezu..t of Idustrisl Aceidx&Of ioc of Iusiusnce for the
coverne verification and that failure to secure ooverago tinder sociou 25A of MOL 152 can lead to the imposition of criminal pen Wcs
oomisting of a fine of up to S1,500.00 and/or im� of up to one year sad civil pcaalties in the form of a Stop Work Order and a
fum o(:S 100.00 a day agniast me
For dcpsrtmt0W—only
Permit Number
Lot#
:`r;- of ermitiee Date
SCION 8� ON5RUCTION 4SERVI CES
8 1 Licensed Construction Supervisor: h{r: 6c Not Applicable ❑
Name of License Holder: �ri� �� //i'J � e1 ` "' t�a<�Ti� 072T 9"-17
�. License Number
Address Expiration
E
ignature Telephone
Pffle errlm r. vemen : n r 21 _ Not Applicable ❑
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 affidE
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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,you may be liable for person(.
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
,9 IN �
EC7ION S R PTIONOFPRPOSEDIVb'2KUh�eck 3 lla livable ' ��
S7 3' ffil.a
New House ❑ Addition ❑ Replacernent Windows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bidg. ❑ Demolition❑ New Signs ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: (Z-e A Jc4 et, `' cnEC
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement. Yes �No
Plans Attached Roll ❑- Sheet 0
f Ne h—OT a tid or addition t'"eA trnf" ink'Vd-0 lete2th'd.1Iow1ng:
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. Mascheck 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
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
SECTIONiZaOWNER'AL1t=I�ORIZApTION TO BE COMPLETED WHEN
OWNERS AGENT QaBC4NT#2ACTOR'APPI.IES FOR 81111.b1NG PERIVI'1T
as Owner of the subject properl,
hereby authorize (I�A/h7,,5 to act
my behalf, in matte ative to work authorized by this building permit application.
L'
Signatur ne Date
�� — fly"�"��TX' ''r, �� � t `� as Owner/Authorized Agent
14 J
hkaiary declare h t, tatements and information on the foregoing application are true and accurate, to the best of my
knowledge and belid.
Signed under the pains and penalties of perjury.
P ' ame
Sign ture of wn ge Date
}
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
s A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW " YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
� r
rG City of Northampton
Building Department
212 Main Street
Room 100
1 ' 2 3 2004 Northampton, MA 01060
ph�ne 13-587-1240 Fax 413-587-1272 of to
- APPLTt; TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-SITE INFORMATION
This sec#ion#o£be completed by'`ff�ce
1.1 Property Address: ,' 3�
Ma Lot
Y
p n�t `r
Zone Overlay District
Elrn St."Diswct CB-,,District
SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
ame(P mt) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
(Print) urrent Mailing Address:
Si nature Telephone
SECT�ON:3 - ST CONSTRUCTION COSTS:
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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 Official Use Only
Buildi.pg"Permit'-Number: Date Issued:
Cigna#ure: _ -
B,uildi g Corrtmissloner/Inspector of�Bu,dings Dade
File#BP-2004-1317
APPLICANT/CONTACT PERSON COLIN HOFFMEISTER
ADDRESS/PHONE 25 Phillips Place Northampton 584-4665
PROPERTY LOCATION 4 ORCHARD ST
MAP 25C PARCEL 160 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL REPLACEMENT WINDOWS&REMOVE FIREPLACE HEARTH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 078842
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm StreoCosion
zf�0
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
"4 ORCHARD ST BP-2004-1317
Q.IS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 160 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1317
Project# JS-2004-1978
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: COLIN HOFFMEISTER 078842
Lot Size(sq. ft.): 14897.52 Owner: LOMBARD JOHN&ELIZABETH
Zoniniz:URB Applicant: COLIN HOFFMEISTER
AT. 4 ORCHARD ST
Applicant Address: Phone: Insurance:
25 Phillips Place 584-4665
NorthamptonMA01060 ISSUED ON:6130104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS & REMOVE
FIREPLACE HEARTH
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• Receipt No: Date Paid: Check No: Amount:
Building 6/30/04 0:00:00 643 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo