18C-099 (4) .-cttAMP
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"'=m _ D EPARTMENT OF BUILDING INSPECTIONS �'
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ow "
WORKER'S COMPENSATION ri'iSZTR.A_NCE AletillAVIT
1, Nelson Shifflett - Valley Home Improvement Inc.
(Iionse ipermitttee)
with a principal place of business/residence at:
340 Riverside Drive, Northampton, MA 01060 (phoney) 584 - 7522
do hereby certify, under he pains and penalties of pen ry, tha'..:
( X) I ara 2 employer providing the Following worker's comp° or -
•
^salon cover
employees worong on this job:
A.I.M. Mutual Ins. Co. WMZ8005610 01 2007 2/1/08
(Insurance Cornpaay) (Policy -:.er) „, i on Da:r_)
( ) I am a sole proprietor, general ccn -actor 0: 'homeowner (ci.cie one) have hired
the coati listed below who have the folowinz worker's compensation :olic:es:
(Name of Contractor) (Insurance Comcan,1Po ic' Nu.m cr) ( -x .acs Dacc)
(Name of Contractor) Jnssrnc: Comca 'PC! Number) �\� z oa Date)
(Name of Coac'ac:or) (?asur ace Com?p2 euc.- N;imbe) sacs Dale)
(Name of Contractor) (Insurance Compa_r •/PoLer Number) (E CLdton Dam)
(anac� additional saod if necessary to dud i fxmance per-aiming to ail a- aeo:s)
( ) I am a sole proprietor and have no one worfdng forme.
( ) 1 am a home owner performing all the work myself.
NOTE: pl=se be aware that while hemeouvera who =ploy per„^as to do x___dmaaani e, ccremuaion or ; u work an a dwelling of
not most the-a throe unite is which the homeowner resides or on the grou appurtenant tbo-c o arc opt geaaaily cooside ed to be
=ploy= under the worked% asrpematitn Ad (GL152.ss 1(5)), application by a homcowtxr for 3 Haase a permit may evidcace the
legal status of an employer under the Work Compemation Act
I undcstand that a. copy of thin ctaremost may be forwarded to the Deipertmrra of Indusaisl Aecder:al Q.T.roo of irau eace for the
oovcage verification and that failure to secure coverage under section 25A of MOL 152 eta lead to the iaupmitioa of aimiosl penalties .
cocaie•,i g of a fine of up to S1,500.00 and/or immisocomem of up to one year add civil penalties in the farm of a Step Work Order and a
Eat of S 100.00 a day tg*irest me.
Signed this / - 7 day of ZOO For d al use oily
W 14/ffill% Permit Number
%' L$l/V shf-i-77-
•
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachuset`s 0108
Home Improvement Contractor Registration
Registration: 13
Tape:
xp ration: 1 Oil 12002
STEVEN A. SILVER %1AN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MlA 01073
Update .address and return card. Hark reason for change.
-address Rene`%ai — Employment Lost Card
Board of Buildin, Regulations and Standards License or registration alid for indiv idul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. if sound return to:
ReSistration: 3 ^, 046 o
Board or 3uildino 2 uiacions and Stands rr:s
One- �shbur:on . :aye Rm 130!
E
ratio n: '.C/112008
3oston.7\ la. 0 ;
Type:
STEVEN A. SIL ER .1AN
STE. EN SiLVER...';;■
268 FOMER RD.
SOUTHAMPTON. 73 Deputy -Administrator Not ' aiio is ithout signature
• /lv '�a�xrra.nii��a 17,a;;(1( welt
BOARD OF BUILDING REGULATIONS
7 License: CONSTRUCTION SUPERVISOR
Number: CS 0 772
Birthdate: 06/21/1664
Expires: 06/21/2008 Tr. no: 24270
Restricted: 00
STEVEN A SILVERMAN
268 FOMER RD
SOUTHAMPTON. MA C1073 Commissioner
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S teven Silverman _ 077279
License Number
268 Fomer Road, Southampton, MA 01071 6/21/08
Address Expiration Date
584 - 7522
Signature Telephone
9. Registered Home Improvement Contractor:. Not Applicable ❑
Steven S ' 1v qs ..t 131945
Company Name Registration Number
268 Fomer Road 10/13/08
Address Expiration Date
Southampton, MA 01073 Telephone 584 -7522
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 X 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 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which heishe 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 -vear 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 thq 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
• ?N $- DESCRIPTION OF PROPOSED WORK (check all applicable)
Ncw House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rootinc
Or Doors"
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding`) Other ` ]
Brief Deseribtion of Proposed Work: Mid / V I P ('t ietA) J s 1 f pI me +se CU;)
Alteration of existing bedroom Yes / Vo Adel :ng new bedroom Y > No
Attached Narrative Renovatr•R unfinished basement Ycs xNo
Plans Attached Roll • Sheet
6a. If New house and or "addition to existing housing, 'complete Vthe following:
a. Use of building : Cne Farmly Two Family Ot :'er
b. Number of rcors in each family unit: Number of Bath rccnis
c, Is tr:ere ° garabe attached?
d Proposed Scuare footage of new Construct 3r1 Dimensions
c. Nur-lber of stories?
f. 'Aett'o: of heating? Firep:aces or 'NdodStove. Nurnbv of each
g Oc^servatic, Lai. ia.-ce. Mascheck Enc Compliance form attact•ee?
Type of cc'.structicn
:s co titr ttCn within IOC "t. of v;et ands? 'ies NO. Is C3nstruct ::,n wlhlr 100 yr. '1 =1:.)la,n 'ft, Nu
Depth of oar,eer:lent or cellar tionr oelov, •^rshec gr.1d
Will building cerfor•n to the I3urkang and ._JnriR r•vgul.7trc ^s? Yes 1•10
I I
Septic , enk C.:y Se'A P r vA we,1 Cry water Sapp y
SECTION 7a - OWNER AUTHORIZATION • TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ /% w as Owner cf tip subject property
hereby .authorize Steven Silverman, Valley Home _ Impro _ v _ ement.,_Inc. to act on
m> tc' If, in all : re!ati to w01s authc'iZed by this burtd np permit aopirc.aticn.
Signature o wner Date
1, _ _ • _ ,,, • - 7- • • • • • , as Owner /Authorized Agent
hereby declare that the statements and information on the foregorrg application are true arid accurate, to the best 01 my
krcwiedgc and belief.
Sig under the pains and penalties of penury. y 4
Steven llxe - ! -
Print Name J _
1111 _� 6
Signature of O.'ner /Ag t 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)
n of Parking Spaces
Fill:
(volume & Location)
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:
•
•
Department use only
(; �; f■ \L \pity of Northampton Status ofd it
.- BI uilding Department • Curb Cut /DD�wa e it •
212 Main Street Sewer /Septic Ava i f ty h am.
Tit_ L 1 9 2C07 ..T. -' Room 100 W Jr /Well Availability 3 t,� 1 .,
.,,
orth ?mpton, MA 01060 Two Sets o fructural Plans
i. - -- : -� !pne 3 -58• 1240 Fax 413 - 587 -1272 Plot /Site � L- t - -. ,
C — n ' �•,,, - J Other Speck �s ', �� `5
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
7 G --�-- 6j � Map Lot Unit
A 1 -1 Zone Overlay District
Elm St. District CB District .
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT s .
• 2.1 Owner of Record: l --t-- C /( t' '
�`' /I4 '1'x" . �7 e1 7 (-__ h� /-� .��� ��� ifs
Nam= Print) Current Mailing Address:
• ' Telephone .— (77/ �i L/
Signatuu- / 6 /
2.2 .. orized A:ent: Steven Silverman
Valley Home Improveme t Inc. P.O. Box 60627, Florence, MA 01062
Name (Prin Current Mailing Address:
'� 584 -7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ,off 00 (a) Building Permit Fee
. L-��
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) a . oto Check Number ?4�1 I 1' 6
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date 1
BP- 2008 -0067
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
r u
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2008 -0067
Project # JS- 2008 - 000096
Est. Cost: $20000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Valley Home Improvement, Inc 131945
Lot Size(sq. ft.): 7492.32 Owner: FINN MARY MARGARET & MARIBETH
Zoning: URB Applicant: Valley Home Improvement, Inc_
AT: 19 GLEASON RD
Applicant Address: Phone: Insurance:
P 0 Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON: 7/19/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW ROOF,VIINYL SIDING & 1
REPLACEMENT WINDOW
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 Signature:
FeeType: Date Paid: Amount:
Building 7/19/2007 0:00:00 $25.0022797
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo