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18c-058 (6)
¢�tiAMP2, � 'Alt Crtg al Naz#El&n4 n -* T9B a=ATP. Atassacfnsetis ` '"T:- DEPARTMENT OF BUILDING INSPECTIONS — r =t 212 Main Street • Municipal Building `-- Northampton, Mass. 01060 • WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, 5-1* lie/51L V et, 1//z-i ,v /tom E n/f tz//13.1-�%Lc._, (licenseeJpermittee) with a principal place of business/residence at: 3 y-e.) ///A$I.b E..,i i I i./ / 7 /i, 7,4 (phone#) -'7$22__ (street/city;stet hips do hereby certify, under the pains and penalties of perjury, that: OI am an employer providing the following worker's compensation coverage for my employees working on this job: / . (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 maintenance,construction or repair work on a dwelling of not more than three units in which the homeowner resides or on the grounds appurtenant thereto arc not galena,/considered to be employers under the worker's compensation Ad(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 Art I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents'Oboe of Insurance for the coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties consisting 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 S100.00 a day against tee. 51-Signed/b ' _day of C- ,J1( (/rf r\. ' -2i0 3 For departarentnl use ally Permit Number - ��' _4 '� Afet V Map Lot# ignaiure ofLi..• -- "min" 'tee • L-f:77(te noitevetzletie, 0 .„,(147jacitizet,„ Ottice ot Consul onsumi Aftl r‘ usiness and Regulation n egu anon 10 Pa--k Plaza - Suite 5170 Boston Massachusetts 02.116 Home Impro‘,-,ment Contractor Registration Registration, 131945 Type' individual Expiratory 10/1312014 Tr* 232370 STEVEN A. SILVERMAN STEVEN SILVERMAN 268 FOMER RD, SOUTHAMPTON, MA 01073 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card cnt>c,s KM Z-74, 6(,411-mt,A /4to‹wil' („„um„,idyars A„ •„,.8i;",itgut;Hrn 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 -- Expiration: 10.11312014 Individual It!Park Plaza-Suite 5170 kX4\ Boston,MA 02116 STEVEN A,SILVERMAN STEVEN SILVERMAN jy,6- 268 FOMER All SOUTHAMPTON, MA 01073 I' nuro.tcretar. 'Sot v.alid without signature rttl' . '211144. - /2.2*„4- SECTION 8 -CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Stev_en Silverman 077279 License Number 268 Fome R..: . ., , _ „ . silt , MA 01073 _ 6/21/1j' Address / Expiration Date ifil (� j! ,i i i 1 584-7522 Telephone Sigma r or p hone a Registered`Home Improvement Contractor: Not Applicable ❑ Steven Silverman _ _s__ 131945 Company Name Registration Number 268 Forcer Road 10/13//i”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 lift 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 heishe 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, 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 ------__ _ --— , • , :r,,,,, T I N ••• ES CRI PT IOIC__._.,,Q_ Ijs_ivi 1 I,_up,1,,,,,i,ohlt,) t , New Hu f:e L.:. 1 Addition LI Replacement Windows , AIteration( )X Roolinn P 1 Or Doors :1 1 Accessory Bldg. 2 ' Demolitiar New Signs : I Decks ; ) Siding Irr ) Other , j i 3 Dec otrt r,t', tEE'r: ro-..er: .'r o-0,, /45r-bi 14_6 068 s 4:424 kviee, 36 tv,...g.:010.) C IS al 6 4c k -6Froe. tt,tttr,tr:-ty.ttrti ttt' )-tity,tcrtr: tittnttrt.-.'ttyl YtItt I7)< No. 1",cri,n2 nt.): lftd,f:n-` Yf!--:', ?‘ r,,Irr /YiStfh9 toi) 4tiecte,.; %art tikr...,- tttettutiot), ii „It't-tit,Ite,„1 uot.semttitEt. 'E;tt.-tt.., 4t.., ft.t.t.o:h(tt:t RV S-E,t:tett _____ 63. If New house and or additicIn to existing houing, complete the ,,, ti,,,E .,....4 Dudc,r,:i.: . C'E. :72m I% titef 1-Et' trF, . E.A,,7:11 .ar'i,y it-,Et: n 1 r,k.:;,:,,"1( tit:thtt e tuttEt-we ,,.°, IleVA' ,,,,W.1;Ott:"dr1 '. V C:r.:.11 0' ttt,Ett.)0Ng' t r t-r: t.tti,ttrt, tir Woctelt.ttut,tt.ttt., ktrt-E-Ltz- t). eocti t 2 E'ert:tty Cc.-7-.ervi„,;tc.-t Ctot---;:, Enc•gy Ct...trtE);_tit,t---.AI:c rx-rt alct.c0 ly,Em ri tt-x:tttt,Itt,..r:ttc,/ E '. t,.cct•tt.,0E..;,:l.tcto kt) tht.tt I(X) 1 or tott,et E.‘citt;s? Yes N:... ii, cr)rtstr,..tt-,:t .-)11 oi;1'.stt Et,00 yi. i f at ,..),1 itint1H1 ..;-!. c(fL4r I :Air ,*,-re10,/ "1,! c, gt,ieltt.- i t t tt: W,ft txt Idy'Ft: co*fur-ti to .t.tt lEt3u tic,t 02 t-ori tt.ttg..1,-)tto's? tYtztttr, _ ____ ttlr) t t t E. Sti.-.1C, 7a*Ilc C, :y 'Z:,,cl'A'tf Pt t.t.ilte we] y______ SECTION 7a • OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT — — - - — , C.,11(41(1.0, -4- CY\ar \A(ACI-0(5 Steven Silverman, Valley Home Improvement,. Inc. ^..41' ; , 0 i 7--q., tt, ,), -,,,,q,,,t)..e t,..1 w,,,c,.. 4,1!“.-rt;,,,,,-; 0,, vlif, LE.,....tEr: nit. „Att:tr-tEt: ttlt-ipitrt,t10:, t , — Sti,,,Er.30.3tit.ot ,Itt).:-,er t..,:-..., Stemen_Silverman, val1ey__11ame__lmprsivement.,__lnc. , •-F, :;....,1-4.-riAlitnry 17i:-.1 ,44,,t1fli ticcEltEtc t-tft... -2-tt: -..,*.z.tterrieritt., uric iviAr-.1.1tt',A1 utEt thu r01,4,r..)11 tr? a or:1,c itiott :It t;.. roe ortd ouLt.tr.lte, 0.) lie 1.,,, G.' ivy ',..r.c.,..lcri3c. ,-..n.e-; be1icf , Si,,,- cd ...-,cc- .*.l.: 7.:ki:.,:- ,.i. ztrti tt..- a ,.$teven Silverman_ _ _ ___ , _ / t /ff 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: 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 any proposed changes to or additions of signs intended for the property?YES ._ No IF YES, describe size, type and location: 1 , , C ,_._' '.__.-' � Department use only n sEp ity of Northampton Status of I�e�nity • ,, 2 O t ;:uilding Department Curb Cut/C IWeway,Permit A , 212 Main Street Sewer/Septic Availa6i1ity Electric,Plumbing , ,peCti©n Room 100 W t/Well Availability v ,' Northampton.VA w,or 0 ► ., hampton, MA 01060 1V ets otu rrtilaural Plans , phone 413.587.1240 Fax 413.587-1272 Plot/Site P=„a Other Specify 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 150 Y (4 Qientle_ Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C iA r t,ci—).\ a-n+ (\'-) .r t 5‘-‘c v-y-)6 ;r� Oya - < � [ Name(Print) Current Mailing Addre I-4\3° �$'�— 2 t Uy Telephone Signature 2.2 Authorized Agent: Steven Silverman Valley Home I rov , Inc. P.O. Box 60627, Florence, MA 01062 Name(Print Current Mailing Address: At,� � 584-7522 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)to be Official Use Only completed by permit applicant 1. Building 11 li'D (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 l 6. Total =(1 + 2 + 3 +4 + 5) Check Number 3) h g This Section For Official Use Only Building Permit Number: Date Issued: Signature: -- Building Commissioner/Inspector of Buildings Date File#BP-2014-0357 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584-7522 PROPERTY LOCATION 150 PROSPECT AVE MAP 18C PARCEL 058 001 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 f/p �•7�9) gs-- Fee Paid Typeof Construction: REPLACE WINDOW W/SLIDER&INSULATION 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 C- o . .../LV- a /"... ,-- ,P3ig Signature of Bui ding 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. 150 PROSPECT AVE BP-2014-0357 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-058 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-2014-0357 Project# JS-2014-000600 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.): 40336.56 Owner: MARKS CHRISTIAN&MARIAM Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 150 PROSPECT AVE Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:9/24/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE WINDOW W/SLIDER & INSULATION 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 9/24/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner