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,.. . cm--4.-2 DEPARTMENTT OF BUILDING INSPECTIONS
•. 212 Main Street ' Municipal Building
Northairipion, Mass. 01060 ' ■ "
WORKER'S COMPENSATION DISURANCE AFFIDAVIT
L 44.c.z_50.kr sw /f---
) (licerstelepennittee)
with a principal place of business/residence art:
3 , -to ,e,i eziL5 ib /e/' ,x,Ae_, Aw (phone4) - - 8 `/- 7
(s e - t r .. jic . ity ,I stat _ thip) e y, , O4 ef3
do hereby certify, under the pains and penaltiies of perjury, that:
)<) I am an employer providing the following orker's compensation coverage for my
employees working on this job:
.,Sz2e5s J4.5. (270. 55 i
„..- ....„
(Insurance Company) policy Number) (Exciiration 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 Caorparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiraton Date)
(prtr-li ackiiticnal thee if nezczary to inciudo irlonna.li on p&rlaig to all contra:lore)
( ) I ani a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: pichee h...- aware that wiulo bo wo lay /:x to do rrr.irrrfft.sic eonstruccion or =pair work ou a dwelling f
not more than three units in which tioa hoto../ner Mia466 Of C the grOarldS aprAlzte, Ant in_:... are not meraLly considered to be
o:np/oyers under the worker's ocmomnican Act (GU 52.,rz 1(5)), ?..7cltio by a 04, ef,.;.,..7,= far e lir-, cc permit may eftitt IN'
lev-le of = c.rs9Itoyer tir..;kr the Wo.-k.ces Conls_e_..,sdio ft...L-4_
I tinteranoci that a copy of thin rt,,t may ha rca to tie Dar.,./ t of 1 li.davts' O of Imintooe for the
cx.werage vcrifition and tht failure to steurt cow tnIcir zetticia 25A of MCIL 152 cnn lead to the intposifion of aimilal penai.6e6
c o n eiatirxg of a fine of up to $1,500.00 ws.f/c.r lrnprzunietlt ()flip one y1;5:r find civil penalties in the &fin of a atop Wed( Order and a
fine of S 100.00 a day aginst =
_ ./— i , .
i.gned this /-:' Hay oi / '412 ,-/" For dep=t1I1C0t51 tial caty
') Permit Number
71 A ki e///-1-- --
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Signattre of I.,,*is../Permitiet.
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I SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0 i l
Name of License Holder : Steven Silverman ..____ 077279
L'iccnse Number
268 Fomer Road,._ ui-'hamnr_ 2
6/21/1
I Address / Expirat.o.i Date
4 ti I
\ ' j 584 -7522 , Ii
Signature Telephone
3 Registered lignie improvement Contractor: F 1t AF, cab ":e ❑
Steven Silverman ..__. _ 131945 ._
Company Name Registration Number
268 Fomer . ._Road 10/13
Address Expiration Date
Southampton, MA 01073 Telephone 584 - ,522 _
SE.CTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (IV G.L. c. 152, § 25C(6))
Workers Compensation Insura 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.
r
I Signed Affidavit Attached Yes N No 0 _1
11. ne
-� Ho Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) n niiIies
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.
Definition of Homeowner: Person (s) who own a parcel ol•land on which he /she resides or intends to reside, on which there
i or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A ; crson who constructs more than one home in a two-sear "e iod shun not be considered a horiicds. n v
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that helshe shall be
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 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 ofl Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated. von mar he liable for person(s)
k cot r,
The und r zned homeo m:1 _, a d assumes i resTon:tibihty ! _zr s tmp c( wE� li) the ::t Bu B ode, t it ..
Northampton Ordinances, State and Local Zoning laws and State of Massachusetts General Laws Annotated.
liotneosvn r Signature
r -__;4 7 .SCRiP1 10 .N_Pf:
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Witty; Ittital:a.! Acditifan Rt2placemcnt Vt`ir,(1:;v0f. ri6cifinr,
CP Cotiy7'5,
ACCES-so J , eeniolitio7 N ele; S gr ] cirg 091E! ,
1)5 O fAL1 ISASII1Mig\ir•
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Ga„ If New house A„nd or addition to housing. coinplete_the
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I SECTION 7a . OWNER AUTHORIZATION RE COMPLETED WHEN
f, OWNERS AGENT OR CONTRACTOR APPLIES FOR Ot,11 PERMIT
71P/f.. t S
Steven Siiverinan, Valley Home Inproverne.nt,
,
I6/ /"16 S55S
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emen—Si.1 ley_tio=e_Iraproir...eament
Steven Silve 12n
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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 column to be filled in by
Building Department
Lot Size i
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/Fnding ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit record e at the Registry of Deeds?
NO DON'T NOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain . brook, body of water or wetlands? NO DON'T KNOW
YES /
IF YES, has a permit been or need to be obtained tram 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 aoy proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
I
^
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- 1 Department use only
, ° ity Northornpt0n
~m�� '
\ 2 UdingDepartrnont
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` 12 Main Street
Sewer/Septic Availability ___ __
R0nnnl0O
Water/Well Availability -
oe o�� ' • p� N0[th�n1ofon. MA 0lO�0 Two Sets of Structural Plans
��� . ,
- ^ phone 413'587'1240 Fax 413'587'1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Li PropoMvAd6ress --- completed '
^ /6 /7165:4 ___ Mar) % IV Lot _ \\ _Unit
Overla District
v�' ^wv�� /�/y)�� Zone -
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��m S�.Di�r��_— ' �-___CBpi$�tt _ (
SECTION 2 `
PMDPERTYOVVN�RSH| FN
-
2.1 Owner of Record:
"�� A
y°�/7 � ~ �(�/'�/�^ ^^ eft-
Nam:(Phn0 Current Mailing Address:
1,
�� Telephone
Signatur 2.2 Authorized Agent Steven Silverman
Valley Ho e Improvement ^ ^'��~ P.O. Box 60637, Florence, MA OIO62
Namo(Prin0 ` Curron��aUing Address:
�/ �0�' ` 7�32
^�0��� �K '__-�N�m __ �-
Signature Tniephono ]
__
SECTION 3 - ESTIMATED CONSTRUCT|ONCOSI5
__
Item - Estimated Cost (Dollars) to be Official Use Only
comoleted by permit apn|icsM.
. Building 8 L Od0 (a) Building Pernn
2. Eectrical I, 1-1(0 (.3) Estimated Total Cost of
Construction from (6) _
3. Plumbing Building Permit Fee
4.
Building, ___ _ ,•, 1110 . ( y. _
This Section For Official Use Only
- - - - - ^`^~'~~'---- -- - ! -- issued: -' ---' ----- --
|
~� _ ___ __ _ -__- _
~ / 8oUdm« CommisskmmY! of 8ulldt:1gs ' � Date ___
�
`
File # BP- 2012 -0371
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 16 MOSER ST
MAP 38A PARCEL 111 001 ZONE PV(100) / /SG_b
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out C)b 7 t / ( 4 / h 0
Fee Paid o I lolo U I ,
Typeof Construction: FINISH PARTIAL BASEMENT
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
IN, FORMATION 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
Demolition Delay
is /y e,
i /
Signa e 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.
. .
16 MOSER ST BP-2012-0371
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A - 111 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 -0371
Project # JS- 2012- 000594
Est. Cost: $17400.00
Fee: $104.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 33759.00 Owner: HOLLENDER FAYE
Zoning: PV(100) / /SG b Applicant: VALLEY HOME IMPROVEMENT INC
AT: 16 MOSER ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:10/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: FINISH PARTIAL BASEMENT
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 10/17/2011 0:00:00 $104.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner