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38B-246 ::t.-\. The Commonwealth of Massachusetts ,- Department of Industrial Accidents . a 'F.4-,:- Office of Investigations �° �=; 600 Washington Street , Boston,MA 02111 '`�#. 1, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information • Please Print (Legibly tt 'Name(Business/Organizationndividual): y�1--/4 mi - y-/ , n//'/ 'f"1U4/ Address: ,-/-' /'//cc-71-5 14) Jig.-1 KL City/State/Zip: / i r/ 2i'/-7)/6/414- 010 6 U Phone#: :3- r - 7S Are you an employer?Check the appropriate box: Type of project(required): 1.CE1 I am a employer with 15r 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no , •employees. [No workers' 13.IOther �Y1 V 0.-} G� . comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • t Homeowners who submit this affidavit indicating they are doing all work and then hire•outside contractors must submit a new affidavit indicating such. •Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Tithe sub-contractors have employees,they must provide their workers'comp.policy number. • I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site • information. /�y _ Insurance Company Name: il,�i y� �1G / �Z / — Policy#or Self-ins.Lac.#: %z/ -' i f 0 Expiration Date: .! /Zo Job Site Address: 3 01\v e S ?Lk City/State/Zip:/UO r-o mp I MA ©t(A00 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _,ties i the - STnPWO RD. and fine line up to$1,500.00 alrCi!/Ur one-year imprisonment,a well as civil penalties in tats form of a STOP eih vv E:1�.�_ORDER c"u�a�� of up to$250.0)a day agRinst the violator. Be advised that a copy of this statement may be forwarded to the° ee.:f Investigations of the DIA for insurance coverage verification. I do hereby c.rti ? ,nder tk' _rains and nenalties�ipernaary that the information provided above is true and correct. Signature: �Ive1/i �//(l !/�//,f��--P f�1.-r Date: [C)/7 /13 Phone#: 44/3-541-75 7 a_ IIOfficial use only. a o not write in this area,to be completed by city or town official City or Town: Per ii,it/License# Issuing Authority(circle tine): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbineg Inspector 6.Other Contact Person: Phone 4: Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 4 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Greg Sandler, Think Global as Owner of the subject property hereby authorize Steven Silverman to act on my behalf, in all matters relative to rk authorized by this building permit application. 10/07/2013 Signature of Owner Date Steven Silverman , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Steven Silverman Print Name /1/ K`2 /� 10/07/2013 Signature o Owner/Agent D to SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Steven Silverman 77279 License Number 340 Riverside Drive Florence, MA 01062 06/21/2014 Address Expiration Date (413) 584-7522 Signature Telephone SECTION 13-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 0 No 0 Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable El Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Valley Home Improvement Not Applicable ❑ Company Name: Steven Silverman Responsible In Charge of Construction 340 Riverside Drive Florence, MA 011 Address Adt i 1 I j (413) 584-7522 Signature / Telephone Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 0 DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Eil Brief Description Air seal attic space, air seal recessed lighting with tenmat covers, install proper vent where Of Proposed Work: needed, install 10" cellulose to attic space SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1St 1,950 1St 2nd 2nd 3rd 3rd 4th 4th Total Area(sf) 1,950 Total Proposed New Construction(sf) 0 Total Height(ft) 14 Total Height ft 0 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone p Municipal p On site disposal system❑ )) Version1.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit: l�l 1201 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability civic,plumbic, Room 100 Water/Well Availability Northampton Gas inspections Northampton, MA 01060 Two Sets of Structural Plans MA�leso p • .• - 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 3 Olive Street Map Lot Unit Northampton,MA 01060 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Greg Sandler, Think Glo 1 3 Olive Street,Northampton, MA 01060 Name(Print) Current Mailing Address: (413) 586-8588 Signature Telephone 2.2 Authorized Agent: Steven Silverman 340 Riverside Drive Florence, MA 01062 Name(Print) Current Mailing Address: �, ��� � (413) 584-7522 Signature r Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $2,000.00 (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) 4', 000,00 0,oO Check Number 31 7(-7 6' This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0447 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522 PROPERTY LOCATION 3 OLIVE ST MAP 38B PARCEL 246 001 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 j� 7 �56-Fee Paid 7&. Typeof Construction: AIR SEAL&INSTALL PROPER VENT&ATTIC 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 FOLLOW TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ON 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 D-••.litio y 1 : �/ /a V647" Signa re 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. 3 OLIVE ST BP-2014-0447 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-246 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-0447 Project# JS-2014-000770 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 7666.56 Owner: G&S SANDLER AQUISITIONS LLC Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 3 OLIVE ST Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:10/17/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:AIR SEAL & INSTALL PROPER VENT & ATTIC 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 10/17/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner