23A-156 (2) •
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m DEPARTMENT OF BUILDING I.NSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
htmn/� 1 %Zi'l1�.
(licensee/permittee)
with a principal place of business/residence at:
.5101 (phone
(strcrf/ci ty,�stat,:lzip
do hereby certify, under the pains and penalties of penury, that:
0 1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
f�G11�bi% �G i� fLG� Well- ��'z`f��� Z-11145
(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 additloml shod ifnecessary to include information partaining to all coahtdm)
( ) I ani a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plc=be aware that while homcowners who employ,persons to do m-btm mce,conovctioa-or repair work on a dwelliag of
not RX"than throe=L'is Which thn home®wn*^Z=64:S or oat the grounds apvurteaant thereto an not gwailly 000ndcmd to be
employs under the workeez.compe=sation Art(0L152,s 1(5')),application by a homcowner for a Gcam or permd may evidence the
legal status of an employer under the WarkWs compaanaiion Act
I uadetsiaud that a copy of this mteasent may be forwtisnted to the Depart= of Industrial Aradaa&Office of Ins uaoca for the
oovaage verificatioa and that failure to secure coverage under section 25A of MGL 152 can lead to the*osdon of criminal penalties
000 being of a fine of up to S1,300,00 audlor kTri of up to one ynr and civil penalties is the form of a Stop Work order and a
fins of 5100.00 a day against ter, y
Signed day of JV, !4 1,,, For dvartm=td use only
Permit Number
Lot#
'Pat=of U ermi6e
SECTION 8 - CONSTRUCTION SERVICES
_I Licensed Construction Supervisor: Not Aplp'icable ❑
Narile of Licensq Holder : Stev '1
x -ye=an--- 077279
-- -
License N,.miber
T-n-f-
268 F ha 7
- " 1
Address
Expiration Date
584-7522
,S gnature Telephone
9. Registered Home Improvement Contractor*. Not Applicabie ❑
g"@-ny Name R131945 egistratson Nlmbor
268 FomgX�_,R -10,/13/
Z±
Address Expiration Date
Southampton, MA 01,073 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 the applicaticn. Failure to provide thisaMdavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... X No...... 0
11. - Home Owner Exemption
The current exemption for"homeowners" was extended to include Owner-occupied Dweilings.oCone(1) or two(2) parnilies
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. i there
Definition of Homeowner:Person(s)who own a parcel of land oil which he'shc resides or intends to reside, on which
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 ill a tivo-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 he
responsible for all such work performed under the building permit.
As actin-Construction Sunervisor 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 Chanter 153 (Liability of EnIplOyLl I-S 10
Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated, you may be liable 1'(-)r persons)
you hire to pet-form work for you tinder this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code, City of
Northanipt(In Ordinances, State and Local Toning La vs and ',-,T,11e of MassaChLisetB General Laws Annotated.
Homeowner Signature
.s.
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sa. If New house and or addition to existing,housing complete the fof lowing.
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SECTION 7' - OWNER AUTHORIZATION -TO IIE COMPLETED WHEN
rt OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERK«;IT
4 J
Steven Silverman, Valley Home_ Zmprovemen Inc :�....r ..a,
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Steven Silverman
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 arly proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
!� Department use only
N 3c City of Northampton Status of Permit:
,00 Building Department CurbCut/Dr`ri+ewayPermit
7U tV ?' 212 Main Street Sewer/SepticAVailibility
:r I
n Room 100 Wad/Well Availability-- `
.."i Northampton, MA 01060 Two.Sets of tural Plans ..,
phone 413-587-1240 Fax 413-587-1272 Plof%Site
zr
Other Spec! r'
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
L— �)k0'c— Map Lot Unit _
Zone Overlay District
Elm St. District C8 District _
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C,rr1 r �rL- ►cv2 - 1�rPr�c
Name(Print) Current Mailing Address:
' Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Valley Home Improvemen P.O. Box 60627, Florence, XA Q1062
Name(Print) Current Mailing Address:
Al 584-7522
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Off iciai Use Oniy
completed b permit applicant
. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing `w Building Permit Fee
4. Mechanical (HVAC)
1 J. Fire e r r oiection _
6. Total =(l + 2 + 3 + 4+ 5) (`r�'; Check Number Z
This Section For Official Use Only
Building Permit Number: Date lssued:
Signature:
Building Commissioner/Inspector of Buildings Date '
File#BP-2014-1130
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 82 PINE ST
MAP 23A PARCEL 156 001 ZONE URB000V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out
Fee Paid
Typeof Construction: REPLACE PORCH DECKING
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
INF9V,MATION 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
Delay
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.
82 PINE ST BP-2014-1130
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 156 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-2014-1130
Project# JS-2014-001924
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sg.ft.): 8145.72 Owner: SMITH SERENA A
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 82 PINE ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.91112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH DECKING
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 Siiinature:
FeeType: Date Paid: Amount:
Building 5/1/2014 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner