31A-149 (3) 15 MAYNARD RD BP-2019-0227
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:31A- 149 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrot: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2019-0227
Project# JS-2019-000367
Est Cost$3000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
const.class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Siae(sa.ILL: 10628.64 Owner: DAVID JUSTIN&JUDITH WOLF
zonine:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT.- 15 MAYNARD RD
ApplicantAddress: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:8/22/2018 0:00:00
TO PERFORM THE FOLLOWING WORK RE-ROOF 6 SO ON FRONT OF HOUSE
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 8/22/2018 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
06 r
Department use only
City of Northampton Status of Permit:
Building Department Cum CuUDiveway Permit
212 Main Street Sewedsep6c Availability
Room 100 WaterAVell Availability
Northampton, MA 01060 Two Sets of Stiuig ml Plans
phone 413-587-1240 Fax 413-587-1272 PloilSite Plans -
"s — r pacify
APPLICATION TO CONSTRUCT,ALT ER, PAi ,R€HOVATE OR DEVAOLl H A NE OR TWO FAIYFLY I)VVELLING
SECTION I -SITE INFORMATION AUG 2 1 2019 1 1 n _ t f_aa-7
1.1 Property Address: sect n to be completed by office
DFP7 OF N�LIAP01060N5 G�Q
1S (YZ( L Yl Lot C / Unit
Zone Overlay District
Etm St.Distmtt C6 Distnet
SECTION 2-PROPERTY OWNERSHRIAUTHORIZED AGENT
2.1 Owner of Record:
W 1 1bMcunrnawd Pd Q W� rna�ai 13otU�oa
[Jame t) . Cunent Moping A dress:
Cjj 5—
Telephone
nature
2.2 Authorized Agent:
egc -) cStk�yyye rl� P•o 6ow(ao(oa� P(o en c MA otoC�2
Name(Pont) Current Mailing Address:
`�l3- S8`f-��a•
Signature Telephone
SECTION 3-ESTIMIATED COF'STRUC I ON COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermita pI
1. Building J nU� (a)Building Permit Fee
2. Electrical J (b)Estimated Total Cast of
Conom-i.gon from(6
3. Plumbing Building Parrott Fee
4. Mechanical(FJAC) •' too
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit(dumber: Date
Issued:
Sianst e:
Building Com sl erlinspamro"rldings nate
Section 4. ZONING All Information (dust Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Pmpgsed Required by Zowng
flus column m be filled m by
Builf"J)'Puium-t -
Lot Size
Frontage
Setbacks Front
Side L: - JI L:' R:
Rear
Building Height
Bldg.Square Footage
Open Space FooLge %
(I them mines bVg@paved
rkol
#of'Pierking Spaces
Fill:
(volume&Lcadon) - - -A. Has a Special Permit/Variance/Finding eve gen issued for/on the site?
NO O DONT KNOW Q YES 0
IF/oposed
ate issued:
IWas the perm It recorded at th egistly of Deeds?
O �` DONT I(NC��r ES
S: enter Book Page and/or Document#
B. he site contain a brook, dy of water or.wetlands? NO () DON'T KNOW 0 YES 0
ES, has a permit been r n"c to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
L y signs exist on e property? YES a NO Q
- _
ES, describe ize, type and location: -
D. ere any oposed changes to or additions of sisnsintended for the property? YES 0 NOES, de ❑ibe size, Npe and location:�� e - a ' , yl .;:_r �, .:ll isiurb mer 1 acre? YES 0 hO
,[hen a Northampton Stann Water Management Permit flare the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all atcplicahle}
have House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
0r Doors 0
Accessory Bldg. ❑ Demolition ❑ New signs [01 Decks [[::] Siding 10) Other tM
Brief Description of Proposed
Work: V �- Rw� (n 54 (�N Fl�d�T (CE1�Ibu,S'�
Alteration of edsting bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
8a.if hlev✓house and or addition to existing housing. complete the following:
a. Use of building :One Family Two,Family Other
b. Number of rooms in each family unit: Number of Rothmans
c. Is there a garage attached?
J. 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?
In. Type of construction
i. Is construction within100 ft.c ;.Lands? Yes No. Is construction within 100 yr. Floodplain_Yes No
j. Depth of basement or caller floor below finished grade
k. Will building corn im to the Building and Zoning regulai Yes No .
I. Sopiic Tz.^.k City Sa.r rri• ec;air ury.,a,5uppry
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WREN
OWNERS AGENT OR CONTRACTOR
�A'PPP�LIES FOR
�BUILDING
IPERMIT
I, u'�11XG +-,yyr , ytp as Owner of the subject
property +1\1� C
hereby xu' ze IVT` tT1
to act o be II m e relative to work authorized bythis building permit application.
gna o(OwneCr ` I Data
f 7tY WYV 11��12yr'Y`Gb➢7 VIZ _ as Gwnan.:uu;ar d
m
Act harsbv declare the,the statements and irm-
`oration on the foreparts application are true and accurate,to the bast of mu kncv;ledca
Signed under the pains and penalties of perjury.
Print li
N I
Sl0naure of OumedAgatt Dam UY
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoervism-; Not Applicable ❑ —5
Noma of License Holder:
Licarse 11n,ber
�,
Address n I Expiration Date
Si,atofe Telephone
9. Reoistered Horne Improvement Contractor: Not P.pplicable ❑
Company
Name {L�,\ n ��n•ero � Registralto�ion Number
umber
Addre0 -Z
ss
Expiration Date
d
E .�.`4`r'f/) d\71"z —Teiephone"17��5 7lJ?�
SECTION 10•WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(61)
Workers Compensation Insurance affidavit muslin,completed and submitted with this application. Failure to provide this affdavitwill result
in the denial of the issuance of the building permit. -
SignedAffidavitAttached Yes....... Qk N....... ❑
11. - Home i Exemption
?1- arca:c:mr,.- i - r .-�.. ., _ cdF idedhinelaria fde•nec-uecunfed EaeEr-r s ' c`a qe(", _ngies
said to allow,such homeowner an engage so individual for hire who does not possess a Lcense,nen.iiod Ihet ditie owner scts
as superng.r.CMR 790 Sines SdMon Sendea 08.3.51.
Definition of T emeowner:Person(a)who own aparcel 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 shuchrres accessory to such wesurd?or farm
structures.A person whoconstructs more than In none In a mrs-sexr neriod Ehall not be renal&tired a ht meowoer.
Such`7aomeowuer"shall eubmit to the Building Official,on a form acceptable to the Badding Of dA flet he/she shah be
re,scrceL a for all such was L nee€.creed verde the bcR Eb g peemet
As acting Construction Seu'eervisor yopi ssence on thejob site will be rcquiredn am time to time,during and upon
completion of Ire work for wbich this per ,tis 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)ofthe Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you trader this permit.
The undersigned"homeowner'certifies and assumes responsibility for compliauce with the State Building C.de,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts Gcneral Laws A oard.
City of Northampton 212 Main Street, Northampton, MA 0 10 60
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
icensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: r)aA6t
The debris will be transported by: y IOp�nnt}(j'�1Q 1VmL�K JPYY1P�l�
The debris will be received by: p 1A 4LAJ l tC� 1 X Q
Building permit number:
Name of Permit Applicant wYYlQ&4—
Date Signature of Permit Applicant
The Coni;nonaueuith ofiti_"assachoseds
_ Dep -rtmentofludastrial Accidents
M " f)fJ,1ee ofdneestigations _
1 600 Washington Street
C'` Boston, MA 02111
.
_ rovww.mass.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lesibly
Name (Business/Organization/lndividual):\ 'a �1��la
Address:
City/State/Zip: '0cy-e ye— \ i 'tl� a� Phone4: Lt 'c)%LA-1522
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with ] 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/orpart-time)? have hired the sub-contractors
2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P IY 9. E]Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5 ❑ We are a corporation and its 10.E]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.E]Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
'Any applvornt bloat checks box#1 must also fill out the sectionbelaw sUo simg Weir works%compeusatiou policy information
t nomeownerswho submit this affidavit indicating they are doing all work and then hire outside conmetorsmeat submit anew affidavit indicating such. '
bCmrmotors that check this box most attached an additional sheet showing the name of rhe sub-cannacmrs and state whether or not those entities have
employees. If the sah-contractors have employees,Wes most 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. '�tttt /��
Insurance Company Name: N(bf'U� T1a--- rifif-ee IICa)D
Policy ... 5,...-as. L.c.-: ..,. -_ ------Expiration Dare: Ohl f
Job Site Address: ( tS�"1�.(�(�,�(� ez. City/StateMp: j)7b Mf}-(jQ(po
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: i52-shah zd-to-the imposition of cr stinal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the fom of a STOP WORK ORDER and a foe
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage grification.
I do hereby certify i the pains pen Ili perjury that the information provided above is true and correct
pp J
Date
Flume \113-
Official use only. Do not write in this area,to be completed by city or town official_
r
City or Town: PermiULicense rY
Issuing Authority (circle one):
1.Board of Health 2,Building Department 3. City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone;,. �
L®t Commonwealth of Massachusetts
� Division of Professional Licensure
Board of Building Regulations and Standards
Constg,5 '1�1V§OgaPsrvisor
�f
CS-077279 ,> _ E3�ires. 06/2112 0 2 0
STEVENASILVERMApcl
268FOMERRO n
SOUTHAMPTON, A 1117'1
Commissioner
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improverl Contractor Registration
_ Type: Corporation
Registration: 105543
VALLEY HOME IMPROVEMENT INC ExPiration: 07/16/2020
P.O.BOX 60627
FLORENCE,MA 01062
\�-
__ , Update Address and Return Card.
SCA t c 20M0517
Office of Consumer aBusiness Regulation
HOME IMPROVE EMENT ComoviCONTRACTOR beoret the ion
for individual If found only
TY , ppa0on before the expiration date. It found return to:
Registrant, Expiration Office of Consumer Affairs and Business Regulation
105543-- a 07/16/2020 One Ashburton Place-Suite 1301
VALLEY HOME IMPROVEMEN�ING Boston,MA 02108
1i�
STEVEN A.SILVER NFr
340 RNERSIOEDR,,,7W
NORTHAMPTON,MA'81062 Undersecretary Not valid without signature