29-386 (6) 04�tiAlhip�O
$ B �assaclTnsctte ,
Grit� of
m DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WOREIR`S COMPENSATION INSURANCE AFFIDAVIT
' (licenscrJpermittee}
with a principal place of business/residence at:
L.�.% `,11.4 (phone#) h��-7S�
(strt~t/city!.zif�lzip
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:
(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) (Lnsnrance Company/policy Number) (Expiration Date)
(attach additioml sheet ifttecenuy to k4adc iafocma3ion pertaining to all ocntrattors)
( ) 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 peaow to do maintenance,,conzmaioci or npar-work on s dwelling of
not more than three units in which the homeowner resides or on the vwn6 appurteavat thereto are not generally coandrnd to be
employers under the workees oration Act(GL15 Us 1(5)),application by a homeowner for a license or permit may avidcz c tho
legal atatua of an employer under the Worker's Compamatio a AcL
I understand that a copy of thin sutemeai may be forwarded to the Nput=ot of Industrial Accidea&Office of Ioswanca for the
coverage verification and that failure to severe coverage under sectioa 25A of MCIL 152 can lead to tha impasdion of criminal penalties
comisting of a fine of up to 11,500.00 andlor imps isocaxrd of up to one year and civil penalties in the form of a Stop We&Order and a
film of 3100.00 a day against t
Signed day
Of v V Yl L � Far c�saxi erne only
Permit Number
Map# Lot#
ignaWre of Li ermittee
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not App!jcable El
Name of License Holder: Ste,%mz _SJ
License Number
Steven Silverm 131945
Company Name Registration Number
�ton, MA 01073 Telephone 584-7522
i SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submi"LLed with this appl[cation. Failure to pro-,.,idc 'his -afficav:t
will result in the denial of the issuance of the building permit.
'
11. - Home Owner Exemotion
The current exemption kx'hmneownors" was extended minclude [000{}) or nvo(2) fami\ es
and to allow such homeowner to en(,a,-e an individual for hire who does not possess o |iccosc. provided that the owner acts
Homeowner:as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Person(s)who own u parcel n[\uodon which lie/she resides or intends/o reside,oo which there
is. or is intended to be, a one or two family dwellina,attached or detached structures accessory to such use and,"or farm
xouc\ures.
Such^hnmeoxuer^ubo|!submit 10 the Bui|dinoOfficial,onaK`nn acceptable to tire 81.1i|dingODidu|
responsible for all such work performed under the building perinit.
As acting Construction Superviso your Presence on the job site will be required frorn time to tinric. during and upon
completion of the work for which this permit ix issued.
Also bc advised that with reference to Chapter l52(gyurkco' Compeusurion) and Chapter 113 (l-iahi)ityofEnup|oy:rsto
Employees for injuries riot resulting in Death)oIthe N-lassuuboactu»General Luv'u Annmut:d. you may be liable!brpr/�son(s)
you hire 1oporfbnov/ork for you under this permit.
The undersiened"homeowner"certifies and assumes responsibility for compliance,"'ith the State Building Code,City of
Northampton Ordinances, State and Loci} ZmningLans and State ofMassuchoycitsOcnmo| Laws Annotated.
Homeowner Sionature
r'
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 atjhe Registry of Deeds?
NO DON'T KNbw YES
IF YES: enter Book Page and/or Document #
i
B. Does the site contaji 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,gigns 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:
{ '�r�€I�.N �� dESCR€PT€OFD OF PRESPO�S[ED i"AR€+ iGhr-ck ,°t€I sJ�€iG��r6�}
Ncw• He use Atdition t Replacement Windows AwteIation( Roafinj- rr
Or Doors �
Accessary Bldg. J Deemolitior+::D New Signs Decks ) Siding 1 Other
3 _t ;
i�I..Z..1�.,~{L..
.� „ .q€;'.k` �:` ,.�-e r.^ '.�t.!. „.�.,s?1 Y `+�� ',n;4.r�s� rr .at;"r�.l :^.fj• _ 1<: /�. •at"
ii
-t��.�'�c� `�`.a�ra�r�. „ .�y°r-�R oz° •oas6��:> u�e..:raa .y __ � V �rf�
6a, If New house and or addition to existing housing, complete the following.
."r�r„ _;� W 't �r �Iry � o t -I; _. ,.. rar r.rr�c�•:fr.0 .. � f'w;.r- E... :` �'_:<r�fi
;r,r>, ear-a� rr :�". __ . _rrc°I; C._ tr::rl _.rI e^ t'�rr T I r.{='ter i :.c?
,°r •d:<lr C'i.r; 'i 0v:€irs ; l I :?f v...t .:.re f'? weS "rl:., 6 r n Str...:€ .,s'r a4`:A;a •„•I_
- ,.• •, ;`,! �¢;�, �t`�rl";i . C=!' I .;rt"us` . :°4^ •� �"•af,�1C�C` s:f6� ,
r
.4 e,
.°w: .r r I'r h:' + _. . .... .....
SECTION 7a -OWNER AUT HORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
a GHQ., L" gtler LL
Steven Silverman, _Valley. Improvement, Inc.,f F�:
17�rtf 14 ,"1:kt k: :fRr Isitl`„ L,,r ..:Elt r;r[!�` I ."t.rI�Y 71..'.�F', k
..,.r
S t e_y�n silv�xt n�_3t 1 ome I t�r4vemetx ,__ Inc-
4�.. _I. ��.�`�_�[��° "„. .'-gr_ .:�rlr�rrr! r.: �Y�n� trrltiarr Q, ._�rt r. ,. Firs.t7re,rti>u a s;r€;�s�,.:lr,,.r •r�, 'U� ,r ,,.f �ar.�.:r .lr-, f;r t:ic; ,.,_.,: a;" rr�y E
_nf ,rlicf.
Steven Silve __.,
E ° ,
Department use only
� MAIR Q City of Northampton StatusofP-&%'I#
uilding Department Curb Cut/DrNeway P$'
212 Main Street Sewer/Se tic AVailalif
Eloctr c. F _ � .�e�tions P y
60 Room 100 W&OWell Availability f
Northampton, MA 01060 Twd Setsof '. 3c#oral Plans "A
phone 413.587.1240 Fax 413-587.1272 Plot%Site
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
Map Lot Unit
3G� �'�J&0"L"�L �
(`' Zone Overlay District
�""tiu AN C IA f�iQC, _
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Corfu,3 ilinkA�ddress:
Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Talley Home Improvement Inc P.O. Box 60627, Florence, MA 121062
Name(Print) Current Mailing Address:
584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Oniy j
completed by ermit applican t
1. Building C j (a) Building Permit Fee
2. Electrical ? ) (b) Estimated Total Cost of
,r (..>f Construction from 6
3. Plumbing d' C° Building Permit Fee
4. Mechanical(HVAC) J
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Check Number
This Section For Official Use Only
Building Permit Number: Date issued:
Signature: - --
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0944
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522 ,igPitt{�
PROPERTY LOCATION 36 BROOKWOOD DR
MAP 29 PARCEL 386 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid V4P' 71F
Typeof Construction: REMODEL KITCHEN
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
INFOYMATION 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
e on Delay lJ
nature of Building fici 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.
36 BROOKWOOD DR BP-2014-0944
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-386 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-2014-0944
Project# JS-2014-001642
Est. Cost: $14900.00
Fee:$89.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groner VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. 1): 26179.56 Owner: LOBDELL ROGER G
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 36 BROOKWOOD DR
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:311412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN
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 3/14/2014 0:00:00 $89.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner