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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060 �,~ No"
WORKER'S COMPENSATION NSUTRANCE AFFIDAVIT
I, 4/ t$4kT Sid /i'r- --Tr v://7-4,c
/ /I7 s_ f fte'/Le_ ...f- - - 7f'/'a/✓ ^Z / .2:71 L
(licensee/permittee)
with a principal place of business/residence at:
3 -to /2 'Z/° 5 / . j r /// / /O, f �, '1 //,4 (phone #) '58 `-/- "7
(street/city!s of *ip) 4 / . /66 0
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
A /.. 5 .6715; C'(.. I �'6 6 5 ! 2
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all contractors)
( ) 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 homeowners wtao employ pawns to do maintenance, construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant are not generally considered to be
employers under the worker's compensation Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Depertmcm of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
coasistin of a fine of up to $1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against me.
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Signed this r day of / 4 4 . ,2t 4' For departmental use only
� �- Permit Number .
// d I / A- Lot #
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N. s B (1110conlifstittsreutitciti:(;110-1 nn e I p t t e -t tri n iv l ai e ts l i l oo t r; f L:1. 1 31 t et t l . 1 11 ) s l s i t 1 I i N i s \
License: CS 7727
Restricted to 00
STEVEN A :SILVEkMAN
-.: 268 F.OME.R.9A
SOUTHAMPTON MA 01073
, . EXpicatiOn: 6/2112010 i I
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( 41111011
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11(1.47260aP/bding-Nlidie94140SfeardifqfP .
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR
-----.•-:'-----=----7-_, before the expiration date. If found return to:
[ M.- . --.- 1 -_- -- 1 Registration: 131945 Board of Building Regulations and Standards
..., ..--.-•.::Z=::.- Expiration: 10/13/2010 Tr* 275412 One Ashburton Place Rm 1301
,.'-...? Individual Boston, Ma: 02108
STEVEN A. SILVEkMAN 1 -- - :. ii ,../1"
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STEVEN SILVERMANI : .
-1', •:••,:::•:;.-= ::- ::•,: :::.::, ••••,
268 FOMER RD. 11 - -1. - :::::::2 -- -.. • • C:;:)„c
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SOUTHAMPTON, MK0-1073--.-
Administrator "INIot valid without signature
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SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not App icable: 0
Name ae of License Holder Steven Silverman 077279
L ccnsc Number
268 Fo r Ro ,
�., - �'n - - - MA 01073 _.._ I 6/21/10
1 Address /Pi I Expiration Gate
/584-7522 ____ _
Sianawr- - Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
Steven Silverman .. 131945
Company- Name Registration Number
268 Fomer ,Road 10/13//
Address Expiration Date
SotathamRton, MA 01073 Telephone 584_7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
I Workers Compensation Insurance affidavit must be completed t and submitted with this application. Failure to provide this affidavit 1
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" s" was extended to include Owner- occupied Dwellings of one (1) or twoL2) 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. you may he 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 Genera! Laws Annotated.
Homeowner Signature
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' PRO,PpSE3 V/ ORK:,;;;.*: Ail ,..;:71
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6a, If flew hotIse and or addition to existing housing. complete the followings
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' SECTION To - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
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1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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zn 4587 4.__EL4e) D/7 SA /17/
. f '.,.'t'.. Steven Silverman, Valley Home Improvement, Inc.
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. Steven_Silverxnan,_Valley_HonteImps,ovement,,,,,,Inc,. ,„,_.,„_,..___„., :7.' !.'' 1 1 " ' 4 '':; 3
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Steven Silve w
I 7°,1 9407
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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: r/
Rear
/
Building Height /
r
Bldg. Square Footage
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Open Space Footage
(Lot area minus bldg & paved
parking) /
# of Parking Spaces
Fill:
(volume & Location) f
A. Has a Special Permit /Variance /Findin: -ver been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded aiethe Registry of Deeds?
NO DON'T OW 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:
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Department use only i
City of Northampton Status of Permit:
Building Department Curb Cut /Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water /Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587.1240 Fax 413- 587 -1272 Plot /Site Plaip..
Other Specify
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This seetion to le
1.1 Property Address: /''
3 J a A Map
� � j �-�1 � Ma Lot Un it
/t
.r /C 97 / /( ,e77/9 , e;vo cob Zone Overlay District --
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT �d
2.1 Owner of Record: ( 5 - ''z, j I- /f10A) ,1z
E/il, t S F- 1- -C4 F 6.1' S• -/ , die-f - r .O,iv, /iA- 6/ i
Na Print) Current Mailing Address:
t_.:0111111111iL Telephone � . _ 7 / ` %
Signature 7 ` E _�
2.2 Authorized Agent: Steven Silverman
Valle Home Im•rovement � P.O. Box 60627, Florence, MA 01062
Name (Print) j /' Current. Mailing Address:
584-7522
r /
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (C (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 1
6. Total = (1 +2 +3 +4 +5) 1 K Check Number 49 <
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date —�
35 WOODLAWN AVE BP- 2010 -0323
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 050 CITY OF NORTHAMPTON
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- 2010 -0323
Project # JS- 2010- 000432
Est. Cost: $1000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 9888.12 Owner: SMITH L DAVID & DENISE LELLO
Zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 35 WOODLAWN AVE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :9/24/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE ENTRY DOOR
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: ® L0/ ' 6 - - /-4v
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA ON OF
ANY OF ITS RULES AND REGULATIO ..
f�
Certificate of Occu • anc �� si ! nature:
FeeType: Date Paid: Amount:
Building 9/24/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo