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t : %Attassaclinartts _ �_
em 42 -' DEPARTMENT OP BUILDITIG INSPECTIONS ~
•. 212 Main Streeir ` Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION NSURANCE AFFIDA'VI'T
, f L s��` sip r �=� . (// - ._- h . --7?7 r / r/L 1�; 2;1
' (Iic seel'permittee)
with a principal place of businesslresidence at: ;
3 v )p/2 j.b2 . 4),21./`Z ,f�b.47t�f'%%r�i�r / `%V (phone #) .- `i- 75"2"
(s(r tIcit '!s',. t.-lzip) ( c•
do hereby certify, under the pains and pen.a.lies of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
/eZ 2,S$S _..-- (-R0 . 6 76 575 r z//42
(Insurance Company) (Policy Nu ber) (Expiration Date)
( ) I am a sole proprietor, general contlacttr 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)
(Na me of Contractor) . (Insurance Conapany/Policy Number) (Expiration Date)
(attach ad:aic of 4 ifnarrveelr to i chhide inform tioo pee aini to all contractors)
( ) I and a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NO M pleaee be aware that whuc h ec e re who easploy peraoct to do n inteoance, construction or repair work on a dwelling of
not more than throe units in wlnth the hointowner td ee or no bay O: uds rArteneat theado or ozoolly id to bo
employta utw1 rtheworlotea om-tt e Ad (CL15 1(5)),eppl.tc iion by a lacmcoc4r, a fora li e. or peceltmay ev + fie
legal of 1's of an Foyer under 6.. Worked -'a Co l +ir. h
1 underond that a copy of this Co a*+-,aot may be Pea t r dccS to the Loert* of lmtu -ie1 AO d Office of Insurance for tbo
co'vera vtrifinction and that failure to swum 0 3Wrago t nyiAt se—iioo 25A of Mt3L 152 can 1=1 . 0 the imposition of o; im.-aal ptnalisrs
wisthg of a fine of 1 -9 to 51,5CO.00 ther . r - of ion ono year and civil pcna1ties in tl form of a Stop Wort Order and a
fins of 51OO.00 a day aphrt me.
. y ' Y
Signed this /.." day of 0 4 4-; :r 1'" { only
der- si rxsa
.71,1 o 1 / l For Permit Number
f/ i d !y a 'V . '_am' / f I l�-a-P I,ot - 11 I
g„ti*re'of I T
Si l
,
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder _ Steven Silverman _._ - ._ — 077279
License Number
268 Fomer a4
Address ,._uthampts�n,..._r€A 0� 073 6/21/12
Expiration Date
Ad4 584 -7522
S gnatur r t r Telephone
4 9. Rmistered tiot e Improvement Contractor: I Not Applicable ❑
I Steven, S z lve^z'man 131945 _ _ _ _._ --- - - - - -- - - ___
I Company Name Registration Number
1 268 Fomer Road
I Address Expiration Date
11 Southampton, MA 01073 Telephone 584 - 7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT c 152. § 25C(6)) 1
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.
I Signed Affidavit Attached Yes 33 No 0 f
11. a e Owner Ex mm ition
The current exemption for "homeowners" was extended to include Owner- occutiied l wweltines of one (1) or tv,.. (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. CIVIR 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 and or farm
structures. A person who constructs more than one home in a two-vear period shaft not be considered a homeowner.
ner.
Such "homeowner" shall submit to the Building Official, on a forot acceptable to the Building Official. that he/she shall I
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 noon
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 ers to
Employees loti for injures nr resulting in Death) of the Massachusetts. `efts. Gcnct I Laws s An v of o aw for person(s)
for ) .
yt to isn`c. 4C7 1'LrP'itYc :.ii i'tie r�. you i,t�;u1/4.i
The i:E ➢Cl rsiLi3Cce - homeowner" L,. i ?t; " =L_,_i "..¢
Northampton Ordinances, State and Local Zoning 1.aw.. and State of :Massachusetts etts Errs, sal haws Annotated,
Homeowner Siitnature
• r- CIJOrl.., - 5 .- 7,...PPs `:[ 3 iPTf ... n : P.E.Y.F3P.PP v'.....P...RI. (c::Pt.= i(t.'j't I() .
t '
lit:Eit.e L. AL:dititil L..! l FlelaLerne.lt Viirdc.wf. A '.:r..it(f.,) i Roctfinl:
11. CDorf, )‹ 1 1
1 i
bleg. 7....: DernIitio7 LI New Signs I De.:.:s : I Sidirg
iA.:
,) 1 • c i
-A--Qi- r [ 4i .
t r , _.„ Ai ■ _ (AO i
Ai EvJ Fez) i ronJ MOid/N, in
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''': ' - '''''.':"-°:' ' : ' I. ' ".. ........' .:Z.................._.......,..................._ — ..,........._......_ ., ..&.... ..i...be... .. 1
6.1 if Nei,: ilottse and or addition to c'4isting liot;sing. cortIplote tile followitp.
. t:t, •
1
: : - : - `7 , :, r' r - t 7 . , :.... ' .:' - ::: ': i ': ., ', , ' _::1 ', .' .' EH: :::: ',.- it^ ' .1, ','['■; Z.t: 1 ',.,(
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1
'-' 4, ..),.11....% yt, .e,„...:1„,..tlel,:t ... ,____It"...t, ____ t•
, ',."i ,".,1 t.,z` ' • ::".t: ,, : t, ■ t t 't:. t ". r,-t. ,:.. :.,.
'
„LAY 't,„;1'1"';', "...'C' 't.tc. ,A_ lir.vi, 1:: ,, -.1 / ' : (:: :-. ' :`,:." ',.. • __ _ r:„t .1' ,,,
'.. SECTION 7ii - OGNER AUTii0RIZATiOri . TO CE CO:y1pLETCD ViitE14
i 0V;1+1,ERS .A.CENT OR CONTRACTOR APPLIES FOR RttILDIN,C1 PERMIT
1
4<- .. / 7 . 1/. /7 e- -
S Silverman, Valley Home Irtprcevernent, Inc .
1 (kc\CI, r ooz_sti----f tAx_
:,,Er?. 0: „Nrit:r
1 1
'merman liall e liozie Int zovemerkt Irie
:1-:,k '..s ":".,.`..`... '... ,.. w. t-.C2r ... .: 0 thul..P u" ;.., ,t..7q...' ..,. •-■,. , r 4ft-, 1 , ;
. t. - 1.,-Itt7f
i
Steven S.ilverrn,-, . . . ..,
iii
/ ?/2-‘34
i
... _ „.
Anr
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 b
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 bee issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis y 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 any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
__--.•'-—
E .—
a 3 . �.. ,, w.,�,.
f
°'v #, i � 4 t F
x
k
" Department use only !
1 t ` "' ° _ ll • ty of Northampton Status of Per
7,a � B •lding Department Curb Cut /Driveway Permit
��. , 12 Main Street Sewer /Septic Availability M
�iw- Room 100 Water/Well Availability
'''.."--:4!''
+ Northampton, MA 01060
Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot /Site PI ' h
Other Specify' ,.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 P`roperr
/
This section to be completed by office
/ / Property_Address:
5,//At . ct� t .- Map Lot Unit _
1-- - , - /ZL - ems 7/1 67416 Zone - Overlay District
Elm St. District.___. ___ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /; 7 sre /C Ds �f
i/ i SZ /�� /-G .,/Ue_. M4- /a '?
- Name (Print) Current Mailing Address:
.
11.. L 7-- ■ Cl. - — Telep -. ..__._
Signature hone 4/ 3 -- 2 6:S ' J-7 7 r
22 Authorized Agent: Steven Silverman C �rJ
Valley Home Improvement:; i , nc, B.O. Box 60627, Florence,. IAA. 01062
Name (Print) i /'I Current Mailing Address:
.i / /// __ /
_ � 584 7522 __._._
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
_._
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building '3 / ,,, r > (a) Building Permit Fee
?_. Electrical ` b) Estimated Total Cost of
I ()CO t/ Construction from (6)
3 - 2 Building Permit Fee
/. Mechanical (FiVAC) —_
i i
;
,= E_, (1 + 2 �- . + h) ' / Check Number &;9 - 7 H 7y
This Section For Official Use Only
Building Permit Number: _ Date Issued;
Signature:
d •
BUltuif ;? CrniYllsssionl 'inSpect.,: of C>L k t. ? Date
197 SPRING GROVE AVE BP- 2012 -0306
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 015 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0306
Project # JS- 2012 - 000499
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 12501.72 Owner: HASELTINE CINDY
Zoning: URA(100) //RI Applicant: VALLEY HOME IMPROVEMENT INC
AT: 197 SPRING GROVE AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:9/28/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL KITCHEN REPLACEMENT WINDOWS
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 9/28/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
AmennimmineliMpr