31A-161 (4) 95 MAYNARD RD BP-2016-1269
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A- 161 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-2016-1269
Project# JS-2016-002179
Est. Cost: $2460.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Sizes .ft. : 7579.44 Owner: BARTON SCOTT W&RANDI E KLEIN
Zoning: URB(100) Applicant: VALLEY HOME IMPROVEMENT INC
AT. 95 MAYNARD RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/29/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE DECKING & TRIM ON SCREEN
PORCH
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 4/29/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterMell Availability,
AN ? No hampton, MA 01060 Two Sets of Structural Plans
phone 413- 87-1240 Fax 413-587-1272 Plot/Site Plans
I Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR„RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Pro erty dress.,:,
Map Lot Unit
tX`t Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY O`F.rNERSHIPfAUTHORIZED AGENT
2.1 Owner of Record:
Val n6 k 16 2i� ( 5 BU MAd (Y\'O-010(9ID
Name Current Mailin dress:
i Telephone
Si" ure
2.2 Authorized A ent:
l PO (D ? "to/el ce Mo, Olcb
Name(Print) Current Mailing Address:
*1 . ze ff& �1 39 `f--"1 CE>2Z
Signature Telephone
SECT10,N 3-ESTEVLATED COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building L (a)Building Permit Fee
El c+ricin (b)Estimated Total Cost of
I d j I Construction from (6) ! i
3. Piumrsing Suildi€ver Parma Fes
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only!
Building Permit Number: Date
Issued:
i
Signature:
Building Commissioner/Inspector of Buildings Late E
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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
parltina)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES
EF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
N0 Cj DONT KNOW 0 YES
IF YES: enter Book; Page andlor Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
6r10mFs+ic to be nFak.,nrfnCd 1 Obtained ( Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there a€y proposed changes to or additions of signs int;nded for¢,le prope!ty? YES �l RI0 �l
IF YES, describe size, type and location:
E. vviii the construction activity dis uro(ciearing,graoing, excavation, or filling)over 1 acre or is it part of a common plarl
that will disturb over i acre? YES I`0
IF YES, then a Norihampton Storni Water Management Permit from the DPVV is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [C] Siding fp] Other*
Brief Description of Proposed �, r` � r,
Work: Rtrl VBG t?�Ll l I u � �� ��)'�✓� � 1 ��(�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6&.If New house amd or addlVon to exEstlng housing coni fete the faHowincl:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? _ Yes No.
I. Septic Tank City Sekiver PriVate v°all City water Supply
SECTIO14 7a-OWNER ALITHORIZAT10H-TO BE COM 6PLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I: • \�J ►Jl`` �`l �1 (� pc.`/l•n Gar of i61r crr ihic••i
E property
I I
hereby author'
to act o y behal in II tte ative to work authorizi3d by this building permit ppli tion.
Sign ture Owner Date
as Owner/Authorized
E Aaet Ft`ereby declare that the statements and inyorma Eon or,the foregoing_nplication are tree and accurafe;to the best of rrlr, knrtrr`+,edoe
I
Sign ,under the pains and penalties of perjury.
f Print Nlame
E
E cinr`-ure_'!Owned
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address ANI h Expiration Date
_ `�
Signature Telephone Er
9.Registered Home Irnprotlement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
&-7- Telephone
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....... No...... ❑
11. Hume Owner Exenoffi
T he current exemption for"homeowners"was extended to include Oirmer-acetr_fed DlyeiHngs of one(!i or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,grayided Fiat Elie Owner acts
as srIloere ts�nr.CT 7800 Sf th Ed`,iion Sectten)
Def niidortn 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.Apersom who constructs more thkn one home to a Mo-year]Uertod 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
responsftlpe for LA such wart:13erffdr med under the buft€[fng permn
As actin;Construction ju en icor your presence on the job site-Till]be required from time to tirne,d7 ring 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 Up-ble 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.
Hornedwne&Signgture
City of ylol�thampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 15OA.
Address of the work: q5 hum orn d ZL
�IA A
The debris will be transported by:
n
The debris will be received by: '
Building permit number:
Name of Permit Applicant � 1 6kQ,_ � Y
� lql�
Date Signature of Permit applicant
i .3 3 ( . .:bei a /4 . C" i4
j « "'
-077279 F
a S
Stam A SA verert
268 Forner Rasd �� F
Srntltamplon MA'01
.• «
012412316
Fm
Office of Consumer Affairs and Business Regulation
7
,' 10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor ldeListration
Registration 105543
Type: Private Corporation
Expiration: 7/17/2016 Tr# 2:54Q29
/ALLEY HOME ! ,"PC '!El,IEI�i i # ,
STEVEN SILVERMAN
P.0, Bax 60627
FLORENCE, NIA 0106
' pdhlte Address and return card. mark reason for change.
Address
Renewal rmploYn7ent Lost Card
I
The Comnion�eafth of_1 assachusetis
of 47,
Ofjl re of Invesligatloals
600 Washington Street
_ter— Boston, AIA 02111
t` ww.inass.gov/dia
Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly_
Name (Business/Organization/Individual): � �'�:� o' Vh, 2 (�`. 'u�a�C'i�� , TO
Address: �b L,,`-��`�'�G�� t,Ji kt;�
City/State/Zip: 'V' -Phone #:
o
Are you an employer? Check the appropriate box:
Type of project(required):
1.M I am a employer with 1 4L�_ 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 g_ ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4;1, and we have no
employees. [No workers' 13.0 Other
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. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ani an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
information.
Insurance Company Ma=: NfbNeM(�
Policy#or Self-ins. Lic.#: C;oc. C, c z i-- Expiration Date: 1k 1 t 7
Job Site Address: 1A f-)n AA bad
City/State/Zip:�
Attach a copy of the wormers' co ensation policy de lavation 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
tine up to$1,500.00 and/or one-year imprisonment, as well as civii penalties in the form of a STOP vv ORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised'chat a copy of this stat: .ent may be for warded to--he Office of
Investigations of the DIA for insurance coverage v rification.
I do hereby certify the pains a°d penalti,,a perjury that the information provide(df above/is true and correct*
Aa/ Date:
SiMture: !< l'�' '�
Phone#: UM—
o fi rgmf a17p n-oh" I)r) ""?t Wrife ist thin arefl, to be t'nrsple!?d by city or tow" official
City or'Town: Permit/License#
Issuing Authority(circle one):
il.Board of Health 2.Building Department 3. City,/To-wn Clerk 4.Electrical Inspector 5.Plumbing Inspector
5. Other
Contact Person: Phone#: