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42-041
.5tiNdp7. O •a'% j dlasaaclTasrtts _ M ' ` :'= DEPARTMENT OP BUILDING INSPECTIONS • •. 212 Main Street • Municipal Building ' Northampton, Mass. 01060 �,~ as' WORKER'S COMPENSATION INSURANCE AFFIDAVIT L 57-i,/S/5/LVY_44/77/, 1Z2__L' ,17 /i f ,i7;?�2//r eitec4%/57/ - (licenseeJpermittee) with a principal place of business/residence at: 3 v ,e/d%Zi�%/... ,-.,_ .�.,-ice /, /L)6:/ 7 r;77/%/zrl n1/4 (phone#) 7 /-75-Z2— (str t/city stafA;ripe do hereby certify, under the pains and penalties of perjury, that: 0 I am an employer providing the following worker's compensation coverage for my employees working on this job: .4-e/6//9'. ./i_sv,464.-/z-e_z bte/7-0-D2J1 W/h/ . (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 Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet ifnecessary to include information pertaining to all contactors) ( ) 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 pawns to der maintenance,construction or repair work on a dwelling of not more than three units in whidi the homeowner resides or on the grounds appurtenant thereto are not wally considered to be employers under the worker's compensation Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may evidence the legal status of an employer under the Words Compensation Act I understand that a copy of this statement may be forwarded to the Dcpartmeos of Industrial Accidents'Office of Iasuranca 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 5100.00 a day against me. Signed a.' day of ('c J 1r' /A 1''t. '--2 (:))_3 For depsrpzmtal use only , Permit Number Arc_,/li,t/ ; .4/ j �y f✓/r/ J' lviag# Lot# pgnathue of Ltcenseellsermittee SECTION 8 -CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License : Steven Silverman_ 077279 License Number Address �� i .,� Expiration/ 1/1_'' 268 F. r a S• - � +- �' •i MA 01073 Date e 84-7522 , Sian. u / r elephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Steven Silverman___ 131945 Company Name Registration Number 268 Fomer Road 10./13/j't 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 ]gl No 0 I1. - 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 andi 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 hi re to perform work for you under this permit.it. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,t_.ity of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 7c.rc.N S. DESCRIPTION OF PROPOSED WORK (check .111 Nev Ilcut.e t.cdition Replat.emeat Window!. A.ter..ttion(Ly7c Rootlets; I Or Doors :: Accessory Bldg. Demolitio New Signs Decks ) Siding = Other t'et.t 0 Le-e- /JO (I4 / Ntr• 1 ,?; _ 4/111A ti,,c)" 6"..a. If New house and or addition to existing housinz complete the following: C'r m 'y :Thr•I I•y "71' f•-,„1••:.•,)?"-1 t,","..—F .7!;71*,!1 t .7;.t,' 'CC,—7 .• 1,, ::•• ap.^::: I C r•"- " Thr fr-'1 ",li t 't f.:Alst‘..g.:t OV yr rtdr,-,::- :tf ; "IP ttt: t° Frtrir-rrttre SECTION 7a OWNER AUTHORIZATION -TO DE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT \10,3-e. 1 • zr.r. _ Steven Silverman, Valley Home Improvement, Inc. 1 trA.- ..7.trtrrt:trztr-r-: to, trio!. rrri: hc ti ury-Ec.•, I . tem.enailxenalani_Valley_HoImprs:oremeat..,—Ing :/:" t:itt J b y, r..7" 1 - Steven Silverman 11 1 (. • ' (,) /1/ /27 " - 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 arty proposed changes to or additions of signs intended for the property?YES ._ No IF YES, describe size, type and location: o � Department use only 1 �/ City of Northampton Status of Permit; �---- —`__` ,. 11) Building Department Curb Cut/Driveway P„errnit '.,,/j 212 Main Street Sewer/SepticAvailability ; ..✓ Room 100 Water/Well Availability lectnc, f �mg&Gas Ins e Northampton, MA 01060 TwoSetsofStructural Plans Ncr'r ''' � "r' ✓�/� }E'rPne fl 4J3-587.1240 Fax 413-587-1272 Plot/Site pI 421: Other Speciff APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: ,J , This section to be completed by office G 1 UOes-rl h�z �” _ I CJ Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pe.\--DX ©o P�ILl��S�h� j /2c', @d react (- Name(Print) 11 Current Mailing Address: Q/Ob Z Telephone Li/3— 63o— 5539 Signature 2.2 Authorized Agent: Steven Silve ri an Valle Ho, e Tm•rov_ment . P.O. Box 60627, Florence, MA 01062 Name(Print) �f Current Mailing Address: irj �� /I 584-7522 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant Building `r( (a) Building Permit Fee 2. Electrical L/C (b) Estimated Total Cost of Construction from(6) 3. Plumbing 17L((,) Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) Vi Check Numbe /16 5 This Section For Official Use Only Building Permit Number: Date Issued: Signature: i Building Commissioner/Inspector of Buildings Date File#BP-2014-0610 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522 PROPERTY LOCATION 691 WESTHAMPTON RD MAP 42 PARCEL 041 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out #2/S7S7 '"'t� Fee Paid Typeof Construction: REMODEL BATHROOM&NEW KITCHEN FLOOR 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 NG 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 / ':old:• D Sire o Buildin_Official ate 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. 691 WESTHAMPTON RD BP-2014-0610 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42-041 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-2014-0610 Project# JS-2014-001030 Est. Cost: $5400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 25047.00 Owner: VOGEL PETER Zoning: Applicant: VALLEY HOME IMPROVEMENT INC AT: 691 WESTHAMPTON RD Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:11/18/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM & NEW KITCHEN FLOOR 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 11/18/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner