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V.4.51,701`. DEPARTMENT OP BUILDING I D G INSPECTIONS * Ul f j f-
• 212 Main Streef~ ' Municipal Building '
, � Sy , �
. Northampton, Mass. 01060 4
WORKER'S COMPENSATION INS CE A AVIT
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V LS cAf SW / /"� %L_L7 i )/,12J/. v / _/-- -- %W'i Pq ,4 4 - 2 1 i i X L
(licenseel'permittee)
with a principal place of busi..nesslresidence at:
3 4- :: //LI 5 ).6 gj/ , /A 'l/7/797,/7J/ i, g (phone #) 5 8 `/- . Z?
(rte 1l ci.ty!s'at :'zip) e'1/6 0
do hereby certify, under the pains and pennit:es 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 Daze)
( ) T 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 Coapar r/Policy Number) (Expiration Date)
ofiath afiditifizati shat ifnec. awry- nho bs& inz nratian palsania ,gtoa51c- traaiors)
( ) I am a sole proprietor and have no one worg for me.
( ) I am a home owner performing all the work myself.
NOTE: please be awra.: that v,irlie horownera wbo r roy pot to do r .,Ni,» err-, ccrsavctioo or Ivpair wark oa a : iv esag of
tot mars than three units in which the homeowner i or an Olt gounds ap At tznt -asst the o arc not en ezalry coositrad to he
employers untr the woti(er`s o:xzx avian Act (01,152 sa 1(5)1 enti tion. by a homaort= Or a !ice° or 11. -rsnit may oVideoce the
lewd s a atao of on ema °dyer =do rho Works* Cooped ico i
I ur.� s t o a d t h a t a . cn p y of ibis t,an s may be Fo.-_-wardool to tJhe C f I ,» ial Arci ' Offiot, of i zu noa for the
cove ge verife :act and t stst f a i n ae to secure coverk, overage n �:. sevina 25A of M.G1,152 can lead to the iapoaiicn of cnmreal p■ltie
"----r4atirtg of a floe of up to 11,500.00 =+l:7z 'frainrhortmenct of aip1n coo yea ai i civil putties in the form of a Slop 1yoric Ord and a
find of S100.00 a day aginst me.
Signed this L day of 4 ; Far depost=ohl use only 1
- �_7 1, a { -- 4 Per pit Num
// ✓ / `) /�i ?" l,' � ' , Mar4 IJot # i
Signature of L' erm tree
si o1Vo1;sU 1L1 fairs and Eftisittess R"L uLtt o
10 Park Playa - Suite 5170
Boston, Massachusetts 02116
Home Irnproverherit Co"ntroctor R.c: istratir n
Registration: 131945
Type: rctciiv21uai
Expiration: 10/13/2012 Tr4 204593
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RCS,
SOUTHAMPTON, MA 01073
I, Irs4s a Address and rt•turn c. rd #, ' ! u k rE assent for tf atv,:r.
kt'crrtsra IteeN al 1 ymeni r rs t t.`;tt°rt
raf t cin. rr • Affairs & 7au irne ItelzeI:ttrfa?t rice €tse €ir regi,icatioo `� alk Cot
HOME Itirrit dciu tt c iir ?t
OME IMPROVEMENT CONTRA +CT aRH ?> 3+src- the e�Ptrat,r €a €1:at .. If found return to
R eclitliration. '131245 r;.p ^, ",rift s`S .f 1:.141 ,1 {IeSi ri t�3fft °t Clk[Iz6'�'r iP�tkl,i t4 - CZ7E
Exp raIton: 10,/1312012 try Part, Piaz., - Su :to 5170
Poston. NIA 021 t>
3,T EVEN N A i .RMA ".4
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s x4.MERRD / / l/
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37279
S I L V E R M A N STEVEN A
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SECTION 8 - CONSTRUCTION SERVICES i
_s Licensed Construction Supervisor: r°t!otApp ice bl D
Name of License I older : Steven Siiv'ermari.__..___ 077279
License Number
268 Fo - r Ro- , .. ton,.._MA_ 01 071 i 6/21/12
i }'de1re;° ExpiraUon Date
f s
584 -7522
S ?nature Tetepuone
- 3, fteeistered,Narne Irrlpravernent Qn : tractc , r: i Not .Appl cab e ❑
Steven Silverman, . 131945 --
r °gist.af,on Cdur,iue c•r
268 Fcmer Road 10/1!3 -/./ -
A.�ddress i Expiration Dada
4
Southamp MA 01073 Tephone 564 - 7522 k
L SECTIOW _ 1OWORKERS ' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, 25C())
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit l
I will result in the denial of the issuance of the building permit.
1 Signed Affidavit Attached Yes X No 0 1
i. -116111C OW tier Exemption
The current exemption for "homeowners" was extended to include Owner-occupied Dwellings llings o <tne (1) or two(2) families
and to allow such homeowner to engage an individual Or hire who does not possess ss a license, provided that the uwner acts
is supery =isor. CMR 780. Sixth Edition Section 108.3.51.
Definition of Homeowner: Person (s) who own a parcel of land on which hi: s,)c resides or intends to reside, on ,ehieh there
is, or is intended to be. a one or two family dwelling. attached or detached structures accessory to such use and' or farm
.:trucnes. A person who constructs more than one hon ft .3 ONO \£':t!` Ui.i to4s Si`s ii i ib tic tutu :ate i_d t, I xk. 4 t'_
SuCo "hom owner shall submit to the Butkinic Official, on <i form acceptable to the Building Official, that hcfsh e shit!! he
responsible for all such work terforrned under the huiltditut ic_e -mit.
As acting Construction Supervisor 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 (Yorkers' Compensation) and Chapter 153 (Liability of Ernpleers to
i ;m io ees felt injuries not resulting in Death) of the \l n-' ichnsetts Gi`.ncrifl Laws: Annotated. sno mar be liable for ocrsltnisl
t..:: I_ n Y1 =.l 110 ne i,,,....1 .emit ,.. I ! i.met. • '_. ( :,. N , 7, t . i ' \,,, ihe ` P t; ,c. t ( :.1
Northampton Ordinances. State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
I o tieowner Signature
' 7C_Ticp!:::--::;',17SDRIP1„0,N or PROPOSED fchti )
Nc 1 :.,r,' ' Acditie t.2, 1 cZeplzt.tAncqt Wiridc:00f, is.,ti r.,..
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6 li Ncv;:_hottse_apdor addition to existing liousitle. complete the follfwi:rt:
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p ,, , ' ' k".".".. "",..'1'' ' ..rt
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; , ',‘g ; "g g',11•1;',,, t'l !'.:*6.': '.. '■... .1...-H, 2,,
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i SECTICN To . ONN11,17.R AUTNOPAZAT:ON - TO DE COMPLETC WitEt4
OWNERS ,AGENT OR CONTRACTOR APPLIES FOR SUR:DING PERMIT
V/7 r(
Steven Silverman, Villley Home Improvement, Inc .
$ ..i.„
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5 .',-.. rt.,:
1 -
Steven Silverman
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This 9lumn to be filled in by
Bui ding 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 any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
a
?Fit S
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Department use only i,
���%�� Cit of Northampton �N�� «�
Status of Permit:
u11 ing Department Curb Cut/Driveway Permit _ -
~ muxowon���n v ' 2 Main Street
,' ', — Room I00
Water/VVell Availability
NOrth8rnpt0O,y�A0l060
Two Sets of Structural Plans ,
phone Fax 413-587-1240 F8 413-537. 1272
Other Specify ,, .
APPUCAT|ONTOCONSTRUCT,ALTER REPA\R,RENOVATE OROEMOU5HA ONE ORTYYO FAMILY QVVELUMG
/
SECTION 1' SITE |NFORNIAT(ON
This section to be completed by office
1.1 Property_Address:
'� /7 57 Map '�' Lot Unit
, �
ui/ - ' / 1 Zone_ Overlay District
Elm St. District __- CB District __
SECTION |2' PROPERTY OWNERSHIP/AUTHORIZED
1
. ,
� 57--
2.1 Owner of Record: ^//� ^��~���~��
'
/ - � / ^»��� 'rY^�1
| . a���� �' / ���J fit ��/� ~^ ~ a 0
Name Print) ' Current Mailing Address:
-
- - ---- ---
T�e�nre
'
2,��uthorized Agent: Steven Silverman
Valley Home Improvement In ^ P.O. Box 60627 ^ Florence, MA 0I062
Name (Print) ' Current MaUing4ddres:
''^
/ 4 S84-7522
�i/ �i�
SSignature ' To|ophono j
SECTION 3 - ESTIMATED CONSTRUCTION COSTS_
Item
Estimated Cost (Dollars) to be | Official Use Only
completed by permit apphcant
1. Building
Cr)) � (a) Building Permit Fee
/ ---------/ / �y�� / \
2. Electrical � �»� (b) Estimated Total Cost of
^~vw� Construction from (6)
- -3 Df.irnhii-iF --- Bailding Permit Fee
4. Mechanical (HVAC)
'I.; Fire Proleclic,ii _ - � - ��
6. Total = {l + 2 + 3 + 4 + 5) Check Number ^�? &y���� � _ |
_____- , _ �_�� ,
This Section For Official Use Oy ___ ____ ___ _____
\ BjiIirg Permit Number: _ Da+uissuod:__ _
__ __ __-______ _
. '
Signature: ____ _ __ - '_-_- ___ __' ____ _
8uUdring Commissioner/Inspector of8uik1ings _ _ Date ___
. .
•
File # BP- 2012 -0307
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 16 MASSASOIT ST
MAP 24C PARCEL 077 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out g�
Fee Paid 0'a 9 2 5
Typeof Construction: REPAIR SHEETROCK & INSULATION FROM ICE DAMS ��
New Construction q t `%Ir
Non Structural interior renovations - r °A Addition to Existing nA �� l�? '" (z
Accessory Structure 1 I �
Building Plans Included: (P(LJ t
C Owner/ Statement or License 077279 r(
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
emol'ti , Del.
r. of B g O fici. l 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.
• w
f �
16 MASSASOIT ST BP- 2012 -0307
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 077 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- 2012 -0307
Project # JS- 2012- 000500
Est. Cost: $3200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 15594.48 Owner: MATTESON LYNN
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 16 MASSASOIT ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON: 9/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR SHEETROCK & INSULATION FROM ICE
DAMS - INSPECTION IF CEILING IS REMOVED AND AT COMPLETION
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 9/29/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner