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," : - DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street 'Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, NV LSO/kr Ek / F-%WT l// Z-/_L' , t',9tt.._ L-;- 29t c
(license&Jpermittee)
with a principal place of business/residence at:
3 `fo ! S J C/nJ/ ii /0,e .07,70 ,tit (phone #) 58 `,- - ZZ.
(street /city!statJrip) D /aG 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 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 if necessary to include information pertaining to all =tractors)
( ) I am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE: please be aware that while homeowners who employ persons to do maintenance, suction 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 000sidered to be
employers under the worker's cue nation Act (GL152,ss 1(5)), application by a homeowner fora license or permit may evidence the
legal status of an employer wader the Wodcers Compematioa Ad
I understand that a copy of this siatemmi may be forwarded to the Departrocol. of Industrial Accidents' Office of Insurance for the
coverage vc ificaiioe and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of aiminal penalties
coosisting 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 0( 3100.00 a day against toe.
Signed this / 5 day of 20/4 For dcparteratal use only
Permit Number
4 - . ',JA ' ,n-ed. Map# Lot #
Signature &L E. •ermittee .
1 SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : St Vell Silverman_ _077279
License Number
268 Fam__eRoad 44 , MA A1f173 6/21/12
Address �� Expiration Date
584 -7522
Signature i Telephone
9. Registered Home Improvement Contractor; Not Applicable ❑
Steven Silverman__ __ 131945 __
Company Name Registration Number
268 Forcer Road — ,_ __ 10L13//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 Ils1 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 -near 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
, !
cf . EDgS R I i_=01 P R___Lop_plioltis
...:
New Hcese Li Addition LI Replacement Windows : Aletation(s)X Roofinc 17.
Or Doors
Accessory Bldg. 2 DemolitionO New Signs : j Decks : 1 Siding I, ) Other : 1
Dc on .,..)! Pu.. Nwk lf N-Evi ° v■ Api ht-e- . ...P...1\-- c ..41,4' I • .
,L.P.,,r,....r
I.Iii.IL: %arrAlvz Qt.--,u7etto:R -„oc..lo.,11 'ow...A-Amy:I 'Ytts, No
Pia' s A.t.:.azhe, l-k 1
63. If New house and or addition to existing housing, complete the following:
:ArictrIE . C'c 7 :1 , 10 y Two raTmly
b N;Arber 17:1 r C;;; F. , f - 1 eAch 'arry :ir "4timni:' npt :7
a'.1;tchee?
; ...1 r,,;:,,,Q", S tt:Ct4;t1 W. 11.:ve: :„0 DrneWpicr,.1'.
,'..• Ntrni:-' :-•,? s.",c-,
1.. Ve'.: o' 'itoti:%:" FOt.-1.1 bC:t7'.., tit WoodI1uv r: u' ooch
, e 1:- Co- servi- 001 ia7zo .... 1sc Enc-gy CorotAan:e for 71 a:tad Ct?
1 of oc
• s co:*0..:.:Ific w,1.11Li 10Q. 't or ....;-: Yt='..c.): No. li) constt„tot,on whir 100 yi, *1,:
Dt '.:.1;tf..f1114:1fti ,..,',: Cel:;ir 11,'Xit" :)E, v:=Sieil af 'It."
bu Idirg cc fDrTi t 0 ".tt: Boildfop, ond
Sttic: -7 .e,' tk C:',:y 1.ieWft.11 _______ _ I'I' vate %%el .C..1'., %.,,mr SALop y _ **
SECTION 7a • OWNER AUTHORIZATION . TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
......______ ..
• //ie:/ ge:- / ae- L-// // ‘c/-___ • as :Avner ct : suLject p-apetty
1y ;-.t.r. nfsn7e. Steven , Silverman,. Valley_ Home Improvement, _Inc.
rr!,,, L'At 1 d 1 - *Iii1 1e, tit •.,101147: by Mif,b,d,'! op, , aniplic"illo
- / 4CC-4-3.4.--% -- )---3 -1?■ -
SritratJo?o: 0 Baer 12:otc
_Stemeli,Stlatermani malley_Home_impramement, Inc. , ,IF,','",wnoriAomo
tv
dcc it IP '7 ". state:gm:71;s and frtiorrliqz:Al on UK: foRIRoir R applo,:dhco ;Jo:: 1ro.q.-. clod otxureatl, to Nit, bt...:-., o' my
kr cw1q.:4;:ge r nd bclicf,
ar
Steven Silve 0 #
_......., .
, r
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by oning
This column t be filled in by
Building De ent
Lot Size
Frontage
Setbacks Front
Side L: R: L: R: i
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 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 arty proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
` Department use only
City of Northampton S of Pe *.rift 4�-
-- __. __ B Department
12 Main Street
Curb Cut /Dvew pip-
SeW r/Septc�Avalla � a
Zd Room 100
.
W FlWell AYailabihty : d .`
J. h ampton MA 01060 ' w•Sets of ctural Plans ' `
DEPT. OP BU e x
No Rr f + AMPro ° 3 87 1240 F ax 413 587 1 plot /Site P � " k
� Other Spe s 411a
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
/3/ /�L- e /c'/ /z cz_ ,, , Map Lot Unit
r /el y2 cz g 4 0/ 0 6 Z Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /), /G oe__ it C /z-od
Cf1 - ? 6 e All / oft. / c L f D/0 a 2
Name (Print) Current Mailing Address:
e --e(A.--/ -. 1A/ - "- 11 --7 Telephone r ..// yz,
✓
Signature /'
2.2 Authorized Agent: Steven Silverman
Valley Home Improvement Inc, P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address: /0 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Li() (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 L//COO Check Number on 73
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0924
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 131 FLORENCE RD
MAP 22D PARCEL 089 001 ZONE URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 7 4SJ
Fee Paid
Typeof Construction:_INSTALL NEW WINDOW UNIT IN GABLE & NEW SKYLIGHT
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
INFO 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 Street Commission _ Permit DPW Storm Water Management
Demolition Delay
f 4� 2 I 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.
131 FLORENCE RD BP- 2012 -0924
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D - 089 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0924
Project # JS- 2012 - 001609
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 1 13256.00 Owner: LATUNER ROGER J & CHERYL A
Zoning: URA(100) /WSP(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 131 FLORENCE RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/30/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW WINDOW UNIT IN GABLE & NEW
SKYLIGHT
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 4/30/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner