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38B-025 (4) 0 ��iiAMp� Q NLYrill • ao w i , . , 4 a �] MAI a< � �:��,• (�� * as4Rrl DEPARTMENT OF B UILDING INSPECTIONS 212 Main Street Municipal Building ' Northampton, Mass. 01060 � 4 'V � y' WORKER'S COMPENSATION INSURANCE AFFIDAVIT //iL$O.Cr sw /G� %L�T /ffz-iL S" C (licensee&perrn i ttee) with a principal place of business/residence at: 3 o ,)/5 1),Lii'Z ? .3,77, ; i1d (phone #) 5 (street /city /s t zip) Ace v 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: Acadia Insurance Company WCA5029908 2/1/2013 (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 Company/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 ifneccasary 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 vale homeowners who employ pasona to do maintenance, construction or repair work on a dwelling of not more than throe units is which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be employers under the woricees mien Act (GL152,s3 1(5)), application by a homeowner for a license or permit may evidence the legal status of an employer under the Worker's Compensation At I understand thst a copy of this statement may be forwarded to the Depert ,cot of Industrial Accidents' Office of Insurance for the coverage verification and that failure to secure coverage under section 25A of MCGL 152 can lead to the imposition of criminal penalties coosistixtg of a fine of up to $1, 500.00 and/or iraprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day against me. Signed this / 5 day of /' 20/2. For departmental use only Permit Number • �► � iteo. Map# , Lot # Signature ofL'.. - 'ermittee SECTION 8 - CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not App icable rJ Name of License Holder : Steven Silverman. _ -- 077279 _ - L cense Number 268 Foil- r Road, .So i .- I _an,, ._ _M21. 0' x_1_7. 2 3 - -_ i 6/21/1 Address i 2- Expirat of Gate hie _ / 584 - 7522 • Signalise Telephone i 3 9. Registered Home Improvement Contractor: Not r' p licab e ❑ Steven Silverman- ._. - _ 131945 Company! Name Registration Number 268 Fomer Road 10 /13117-- Address Expiration Date Southampton, MA 01073 ___ Te ephon ; 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 of ioav t will result in the denial of the issuance of the building permit. Signed Affidavit Attachec? Yes....... X No 0 y�. i 11..... Home C we er Exem l The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of`one (1) or two( Eul lilies and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the ewner acts as supervisor. CMR 750, 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 Emplo„ers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von 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 Dmic RA3TioN or pRorosco_1/4o3:ni5r-r,K. , 0(; 1 1:p[ir.,,, , h1f , ),, N Witrdcw:, A Rootirr. bda,.. Nev; ,41.1,f+::: DECKS Slcir Ort tr P 0 .4-C — Ai f etrw hv Pt)sis , , . If New house and or addition to existing housing, cotrpiete trie following: t,^,t • tttl, t tr t‘t t '4' tt.c.' .• „ t „ tt SECT1CN 7 OWNER AUTIIOR&ZATiOti - TO OE COPUTCD WIICts1 OWNERS ACE,NT OR C014TRACTCR APPI. IFS FOP i3U11 OING PERMIT H. A r't Steven Silverman., Valley Home Irtprovement, Stexen_SiImennan,_Vall.ey_lionte_Traproxentent Steven SlV _______ _ 7/PZ‘) • 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 Buiing Department Lot Size i 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) 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 .t the Registry of Deeds? NO DON'T - NOW YES IF YES: enter Book Page and /or Document # B. Does the site contain .. brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a p= mit been or need to be obtained from the Conservation Commission? Needs to be o• ained 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 +C��tP! , of Northampton Status of Permit: Bu ding Department Curb Cut/Driveway Permit '12 Main Street Sewer /Septic Availabil Room 100 Water /Well Availability : I1 ort ampton, MA 01060 Two Sets of Structural Plans - phone 443- "C7-1240 Fax 413-587-1272 Plot /Site Plans : Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: l (2 0 _ f6 a IA 1 LL TEICP t J Map Lot Unit Zone __ Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: MAW( ©) Nr1L -_ Name (Print) Current Mailing Address: s/ — /�° c - Telephone —_ Signature 2.2 Authorized Agent: Steven Silverman Valley 11.2 a Imp ovem p' , Inc. P.O. Box 60627, Florence, MA 01062 Name (Print) , j, 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 3 5( (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 96 4, l tow This Section For Official Use Only Building Permit Number: Date Issued: _.,_. _ _ __ _ Signature: _— —_ -- Building Commissioner /Inspector of Buildings Date _ 4 File # BP- 2012 -0908 APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522 PROPERTY LOCATION 22 FORT HILL TER MAP 38B PARCEL 025 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out a% �� Icy ur7 Fee Paid Typeof Construction: REPAIR FRONT PORCH ► N SA rvt- FO 14 wr" New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 077279 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9I MATION 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 Street Commission Permit DPW Storm Water Management Demolition Delay Si nature of Buildin Official Date /7-6 Signature Building 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.