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'�W } DEPARTMENT OF BUILDING INSPECTIONS , _':_'
•. 212 Main Street • Municipal Building y 5v �
Northampton, Mass. 01060 •
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 4/2 /-solf sip i ,�� -��
(licenseeipermittee)
with a principal place of business/residence at:
3 ito /) /Z.45 1 ‘)nlr�� j/ f/0,i../717 ,70/r; /'lit (phone #)
(street/city /state/zip) 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 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 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 reen,t.na.r., construction or repairwork on a dwelling of
not mote than three units is which the homeowner resides or oa the grounds appurtenant thereto are not generally considered to be
employers under the worker's ootimensation Act (GL152,ss 1(5)), application by a homeowner for a noon= or permit may evidence the
legal status of an employer under the Worker's Conmeosation Act,
I understand that a copy of this statement may be forwarded to the Depa tmcnt of Industrial Ae idents' Office of Insurance for the
coverage verification and that failure to snore coverage reader section 2SA of MOL 152 can lead to the imposition of criminal penalties
consist:Mg of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Step Work Order and a
fine of 5100.00 a day against tae.
Signed this . / 57 day of 7i 201 For dial use only
Permit Number
0 .420: ,?z Map# Lot #
Sim of L'... • ermittee
L -6
, ,401(
zmcviitt Y; //10 y,oetz
Office of Consumer Affairs and usiness Regulation
.„)
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Reqistration: 131945
Type: Individual
Expiration 10113/2012 Trii 204590
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
Update Address and return card. Mark reason for change.
Address ' Renewal Employment Last Card
DPS•CAS CO sam-o
.1443,,eitase446.
Office of Consumer Affairs & Stillness Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
Registration: 131945 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
.e.t Expiratory: 10113/2012 Individual
Boston, MA 02116
STE4N A SILVERMAN ..
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073 Undersecretary valid without signature
Itlassuclurw,tts, prpartment of Pullin. Safety
9 Board of BuddinA4 Rt./Illations and StatidurdN
Construction SUperviSor LiGeriSZ
Ltcense: CS 77279
Restnclet tn PO
STEVN SILVERMAN
268 FOME,R RD
SOUTHAMPTON, MA 01073
ElDirattorr 8121/21.1
t Tr*: 26858
New &=1;e,
i)ts tirfike) yezt)
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steveri SilyermalL 077279
License Number
268 Fouer - mad, outhampton, MA 01073 6/21/1
Address / / Expiration Date
A1141 1 1 584 -7522
Signat ' e / Telephone
9. Registered Home Improvement Contractor: Not 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 11 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
, t
QTION 5- DESCRIPTION OF PROPOSED WORK (check *II applicalle)
New Flout,e --7- .L.1: Addition U Replacement Windows Alteratio*,14 Rooting 0
Or Doors : i 1 ..
Accessory Bldg. D Demolition0 New Signs ' 1 Decks 1 } Siding I 1 Other
. ..........,,
Dr.:,c-1721., on n1 Pr( Witte Al NeW 51614 CO( AATT:e.--- ILLS , kv All neW p.0)1)454)0, 1.
"1 )-
, 4.• 1:erFts: n` t.ils, biirdcTri YtL 24, \h) And,oR fl,: nerirne
Llt,di.iieu Nartativt- Re'1,:rio tr '..;: ,...1 if cli SIttcl t;oseirtiint
F-'1,:tr:,. At:. Poli Sniteti
6. It New house and or addition to existing housing, complete the following:
;.k Use. ot diidalnE . C'E rani ly 1 r 2Mtly Cot
1 1
1) Nurt ill rCoi 1 each 'arni;y ar,t. Numni.. ot iiF:th
p,n•, aqached?
J rit4,, SQuesit. 1(t*t; f„.:11 - _.c,,,le.t;,,c,t ;;,..o Di - :'it , i11 , ,K,.it,
of
1. Vetrod o' hoottng 1 it fi:ett, ur Vclocdtitovo:i Nii-ln..- of eocli
e F Cc Oor'p iar ce Maschcck Enc-gy C3rnTharize form alacVed?
INI (,I co tichci ___ ...,., ... ,..
c,..4titr,..zdicd w tlic/ 1C) 't cif .e.nos? Yes No, I:, c:5nstruct..7,in v.- thr 100 yr , "IO:glplarsi Ytii, No
1
u.fd of ow,einent ni celi;iir 1 oor deldvi nd giade
k "A"11, zits Ith cor form to ",t Gioldinp, find ?oriong ve-g.ilatio^E'a _ No
! k St lank Cy Sev Pr , .fil , ,,e. we.l City water Sup
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ L'irifie_h //,/,/,e_121 5 .
as 0.4ner ci t subject propEity
1 , Steven_ Silverman, Valley Horne Improvement, ., Inc. , :o an on
ri!,..* br- rt <A 'n' rtlf., tu woe' ,utheelied o Irm, b...1':?: nk ..)eur II a;Iplicativi
SIP,C31:',.ffe Or CMaef
. .S.t.exen_Silmermail.....3taileY Home IMpromement, Inc . , AS aWnflt/Atiinfri761 'Af-rit I
I
hE dee arc Ina; *.ni:: staterrit ::Ild 1r1fOrrlittlpir on the forcRoir jr i.ippliciition tire ',die orrr,i ill:Line:At:, I'd 'tit L>frzi; U' toy
krmlecee no:'; belicf.
- ,cd -nc oal ard p'::•ro" tic. LI Verl',' '
Steven Silv_erm /
1- r,r 1 NAtr.1!
.......,. ___. . _, _
..,..._,..,......._ ..,...,..,„._,_
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 ' ed in by
Building Dep. • nt
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)
# of Parking Spaces
Fill:
(volume & Location) i
A. Has a Special Permit /Variance /Finding ;' been issued for /on the site?
NO DON'T KNOW / YES
IF YES, date issued:
IF YES: Was the permit recorded at $e Registry of Deeds?
NO DON'T KN,W YES
IF YES: enter Book / / Page and /or Document #
B. Does the site contain rook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a p :'rmit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any sign exist on the property? YES NO
IF YES,,:escribe size, type and location:
D. e there ar y proposed changes to or additions of signs intended for the property ?YES _
N.
IF ES, describe size, type and location:
Department use only
, g t ity of Northampton Status of-R,
uilding Department Curb C ut /Drtieway F rtn�t
_ 7 IOW \ 212 Main Street Sewer / Septi c, Ava if a bit t y
Room 100 " IWell Av alla b lllty
,,o p6o orthampton, MA 01060 I' S ets o$711 ctural Plans
"D-' 14: a` ' one 413- 587 -1240 Fax 413.587 -1272 pot/Site
Pl �
Other Speci x
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 GG� ,/. Map Lot Unit
em= Z Zone Overlay District
J Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /7 e // 01 A/ /-
Name (P Current Mailing Address:
Telephone
Signature .461y —
2.2 Authorized Agent: Steven Silverman
Valley Home Improve t, Inc. P.O. Box 60627, Florence, MA 01062
Name (Pr 4 Current Mailing Address:
584 -7522
Sign. / e / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7 5m) (a) Building Permit Fee
2. Electrical /56 (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) v Check Number �6 1 2"j �I J
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0110
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 600 FLORENCE RD - 17 MT LAUREL PTAH
MAP 37 PARCEL 022 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out t
Fee Paid V V VI
Typeof Construction: KITCHEN COUNTERTOPS & NEW PENINSULA
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 FOLL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
- MO . tios D- ay
• 7,s d
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.
600 FLORENCE RD - 17 MT LAUREL PTAH BP- 2013 -01 10
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 022 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0110
Project # JS- 2013- 000176
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): Owner: NORRIS RICHARD & LAURA
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 600 FLORENCE RD - 17 MT LAUREL PTAH
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:7/31/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: KITCHEN COUNTERTOPS & NEW PENINSULA
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 7/31/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner