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' '- DEPARTMENT OF BUILDIxG INSPECTIONS =—„7: t4
=fag. I
212 Main Street 'Municipal Building '
Northampton, Mass. 01060 7~ ow s
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, /f/Et$C f EH /FC%L4_7r , v fz - y /n-� .L�7/�i/>',"Zfi1i, L
(licensee&permitt.ee)
with a principal place of business/residence at: .
3 `¢o 1 C >1/Z./65 1� d xi✓Z 4 /f/O,e74' riff (phone #) 58 `'- 7Z2_
((teet/cit 4/06 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:
Acadia In 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 if accessary 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 who employ persons to do maintenance, ovction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the workers compensation Ad (GL152,s3 l (5)), application by a homeowner for a license cr permit may evidence the
legal ctanua of an employee under the Worker's Compensation Act.
I and sad that a copy of this statement may be forwarded to the Departmrot of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL l52 can lead to the imposition of criminal penalties
consisting of a fine of up to S1, 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 5100.00 a day against me. $ !
Signed this / day of /3 20/4 For dial use only
�'J Permit Number
'/ �� � °. Map# • Lot #
Signature of L` ; L • ermittee
. r'
/1
" �' O fikc of E Consumer Affairs airs and usiness Regulation
u
}
� t 10 Park Plata - Suite 5170
Boston, Massachusetts 02116
Home Improvement Con tractor Registration
Registration: 131945
Type: individual
Expiration: 10113/2012 Tr# 204590
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, N, MA 01073
Update Address and return card. Mark reason for change.
Address Renewal Employment Lost Card
`_ . :Ai g, sosi, -Gas . e
o(( on n n m e ..ou. o4fie � r rx rrse€
( License tsr registration valid for i this °idut use only
mitt. o f C s er Affairs & litisuirss Regulation
1 ` HOME IMPROVEMENT ONTRACTOR before the expiration date, If found return to:
R ., Registration: ° °'131945 Tyne: Office of Consumer Affairs and Business Recoil lion
°, �1, fi Expiration: 10/1312012 lndividaaai 10 Park Plaza Suite 5170
tr
Boston. MA 02 6
STEVEN A S(L V RMA 3
/k
3l if » SILV Rat //i
268 FOMER RD N �'
a_ E
sC1..fTNt ?s P T .?i'd, MA 01073 1:satirrsecretary Not %atlid without si e
)'nasals tilt %ett5 - Department rtment of Putil t adites"
t it, Doiiril of fluthlittv, Runulations amt tatadartts
Construction Sup, ryi or LiounSe
License: CS 77279
Restricted—to:
STEVEN A SILVERMAN
268 FOMER R . ,. t
SOUTHAMPTON, MA 01073 � ,,
cs .�,::,e-- — w 5 stan:attor . 8/21/2012
( a =aal.ct3t`*E <> *rC _.. § r=+: 2818
d
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License d i lder : Steven Silverman __ ___. 077279
License Number
268 Fo er Road Southampton, MA nln73 6/21/12
Address (i Expiration Date
584 -7522
Signature Telephone
9. Registered Home Improvement Contractor: Nct Applicable ❑
Steven Silverman ____ 131945
Company Name Registration Number
268 Fomer Road 10/13//2
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 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(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
i 1
ACTION 5. DESCRIPTION OF PROPOSED WORK (check all applicable)
........_ _.,.., , . 1
i NewrHour.e L: 1 Addition U Replacement Windows i AIteration(s) C ' Rooting 0
Of Doors :1 I
Accessory Bldg. D . Demolition:I New Signs : 1 Decks ' ) Siding Other: 1
. .. _
3 Ec-.:c on Pr Nc,, pittee- tc) - 7 1 1 . ) -",, ) 'irii" 50 t A I n VrirtovS Aff'As --
.. ri4r.e: flKirr:c.-4
:-.1:6t:ht..%; %cit'refth.',*: ‘e` ,lifkllt,h.^. t:tv,rustlr:t 1 .":,•1, Ns.,
Pb - s •..ttzl:hc7.; Pot'
6a. If New house and or addition to existing housing, complete the following:
w.E. DI :-Alic.n-ii.: . Cc rani ty Tw\ 7 rmly
i
b. N.3r)El 17;1 rco—s ,-1 ea 1.7 tr
k t a a alachee?
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4 .. 7 Clf*011 c it. I ner. e,'...f.::, ut Wecx..k,tuve Ntr u‘
Er:5" Cc. ia .,... _ IViz-icht2ck Ertc-gy Cpm,DFD11:e f:Ir-ri w.t2,chce
1. ..-..1 4.....c-f.lnthci
• oi I 1C.a 't :'.it ^4et. les N,I,..:, is r.onstt;Jet w,:ri. 100 yt *1,.::).,4,do Yt.: r
1 aw.i.,rTttit f 1 I ::..fir tlelnor '1:'.1f gt,
:VICII cc! r)t !e:', xtd ?2,!'4F1 t4.,..1.1tIC' ",? Y:71:7. ND
. SL1.1.1C - Z.! . uk C :y : Pr viVwe .e •:.;y v So.,..41 y
....1
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner ct t Bubject p!
to. :-.u!,-.4nroil S ey_ep. Silverin4n , Valley Home Improvement, Inc.
rn. Lrivie r! .il - le -.I 7 t, * r.1,i - ti ,Zt. tti vi.,7,1.i 6tIttitrt;ed by, INS, 1:, tip, , 1:
- t
II tom 1 aut-wlidt __LW/
• ...at,e3r_en Si. lv_essaan........MaL..el y_liome......Improitement, Inc - „, c....„ ipoirm-1761 r-.26rA
hC:.° dec'Fre:'" ".nt:1,:alcrric und fr,71.11!on tr! the fotep,rotr i, are t-ue cind ucc.or:Ite, to :he tp,-,-.., t;'. try
c?..lecc.!e ,7nt belief.
SIZ .1 :1 D:34'1: .1 r,:"..7'10 t.le.:1-: Lk
Steven Lily ran. / / 7
/
Pr3 I Narr.::
,,i
. , '
_,.„„...,..„,-- r !',... ,.. ,,,......,—.....*.... , '
71;•.1'”. //er
J, C ,00
Department use only
y _ y; -Litt' Northampton Status ofPe,J1t
Ho! g Department Curb Cut /[riVeway tx►rr�a
jilt I 2012 21 Main Street Sewer /Septic Availa fifty
oom 100 W e, /Well Availab
41Q.dha pton, MA 01060 t Sets of ' aural Plans
._3 ='587 1240 Fax 413- 587.1272 Plot /Site PI r' ..
Other Sped
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
�o d N L /f2 c� % Map Lot Unit
' r Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /1_ �, /Z_ S /
J (- #t�.? // C / erretnt 7///l /J/? / 1 , c ) N e (Print) n Mailing Address:
/Sitfti h Telephone �= j
Si �� ✓L'J J /
2. Authorized gent: Steven Silverman
Valle Home I:•rov -,, n P.O. Box 60627, Florence, MA 01062
Name (Prin A / Current Mailing Address:
. j / 584-7522
Signat re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4 5-0-o (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) 4j 5- Cr) Check Number a 9(7%(p
This Section For Official Use Only
- Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0909
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 60 NORTH ELM ST
MAP 24C PARCEL 033 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out '76 i �K
, ,
Fee Paid f /CJ
Typeof Construction: REPLACE SOFFIT & SIDING IN VARIOUS AREAS
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
INFOAMATION 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
L f 77-6 / Z
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.