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DEPARTMENT OP BUILDfl' C INSPECTIONS _'_� � -
212 Main Street • Municipal Building
°_{
Northampton, Mass. 01060 ' --_-_-= •
',
WORKER'S COMPENSATION NSURANCE AI+'I'IDAVI'I'
I, /U 2 4,-5 c it i 5/1 / /" = -. 7r , ° ///7 --'_ ,' Y L'r7/ .. L ,/� 7/* ;z �C //L-91 /-/ !;;'( r`
( icenser/pernlittee)
with a principal place of business/residence at: •
3 'to /e /i'c" r?, e I; 2 ,,),, ,./ite_- , „..fM/"s, , 1 /77,1 (phone #) '56:' 'b- 2_
(greet/city /state /zip) eJ ✓G+ 0
do hereby certify, under the pains and penalties of perjury, that:
(X) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneccasary to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: please be aware that while homeowners wino employ persons to do maintenance, construction or repair work on a dwelling of
not more then three units in which the horwntr resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workers Compensation A.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' O$ioe of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to $1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against tee. �-
Signed this 3 day of / c / 0 For departmental use only
Permit Number
124 f 6 1 / (a /-'--41-4 Map# Lot # .
Signature of L •ermittee
.
e .
& t III?. . `r . ko
01 cc ol (:onsurller Af'fairs and B Ret4u.latiori
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Reclistratory, 131945
Type: Indivklual
Ev, 10/13/2012 Tr# 204590
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
1:pdate Address md return card. )1:Irk ler chani.le,
Addres-ii Renewal Ernideytrient 1,oct Card
Oli“e or tornotarr flir 4 Iltisilicss Lone or renbtration sulid for use
HOME IMPROVEMENT CONTRACTOR Ilefure the expiration dote. It found return to:
Registration: '131945 Type: Other i.)f tolsit trier Affairs anti BtLries,s Repuiou
Exi3Oratiori.1 W1321 n.uu 1(1 Path - Suite 5170
Roston. T W2116
STLA FR,M,4N
STEVEN SILVERMAN
258 FOMER RD.
SO0T1-iAMPT(11iI liAA 01071 rkden Not solid oithotat signal on,'
t 111 'it id tTiit
til
Cs 77279
t 00
CE A SILVERMAN
501,1THA51•Orl 1T\ QtT r4
6;21,2012
T 268;68
7 SECTION 6 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not App icable LI
Name of License Holder : Steven SilvermaI1 - ___. _. - .. - _ 077279 - - -_ --
License Number
I 268 Fo er Road Southamoton,__nA 07 073 6/21/12
I Address Expiration Date g ,
1 � ��/l I 584 - 7522
Sinat4 e Telephone
9 Registered Home Improvement Contractor: Not Applicabe ❑
Steven Silverman _ - -_ 131945__
Company Name Registration Number
t 268 Fomer_Road 10/13//2
`
tied -ess Expiration Date
Southampton, T 01073 iephor4 584 - 7522
1 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 1
Viork rs Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this . hi a .it
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X No
1. - H ome Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (I) or tsso(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the o lit',` acts
as supervisor. CMR 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 winch 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 -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on <a torah acceptable to the Builc;inL Official. that h t.,hr shall be
responsible for all such work performed under the building, permit.
AS a_.a t, r this(r'.':'rio _"Aki VOUr i.SCi .:.i. Oil .i,. -jOh SiR ..III . . ..__, .1011 r t ti ,
c.Orllpietioll of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter I53 (Liability of € is it ere te
Employees for injuries not resulting in Derithl of the l'vlitsstichusettS (ienen.11 Lars Annotated. you may be liable or ILl '01;;,:;,4
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 o
iiti.triltairinion Ordintirees. State boil hoent Zoning La . ra State car 'tassaei u.ctts (r neritl i earns Annotated.
tlemeos" tiir Signature
,
,
�{ i... �,� , :.. N _ , "` :3i ��� .� � } • 'r� � „�,>� r iti �.�� t a,E S �7;3�::. �: i.�
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SECTION TA - OV NI Fe AU I OsRiZ/ TKO`t TO BE CON1PLETED WHEN
OWNERS AGENT OP CONTRACTOR A-??i,.I s FOR t3 'i .Di G REPI4IT
i I�
CIO 1Cit/UTizi)u1/ez (asf
Steven Silverman, Valley ` ome Improvement, Inc.
l/ �-
✓
Steven_,,.Siiverrn:tn, ._VaU..ey, Home _Improvement, ..Inc .
^9�� t ��a' Eui � it •;aa y °i 's. 1 ,aa
v e
Steven Silverman
/k /2()/
I -
Section 4.
ALL ENFORMATION 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
Frontage
Setbacks Front
Side L: R: L: R:
R
r'-
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 , OW YES
IF YES, date issued:
IF YES: Was the permitjecorded 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:
It
•
"` .
,. `
'.
---- - -- `
epartment use
City Of Northam Dt0n ��t=m |
Building Department 'Curb Cut/Driveway
212 Main Street
Sewer/Septic Availability
01060 �
�� Room 100
` � � u`~ Water/Well
�� / - N��thuNorthampton, 0�. K4/\
- - "
phone 413-587-1240 Fax 413-587-1272 |
Otker
' '-��_
CO
� APPL|CAT|��TOCON8TBUCT.ALTER.REPA|R. RENOVATE ORDEK0OL|SHA ONE DRTVYOFAKO|LYDVVELL|NG
_ __ __
SECTION 1 - SITE INFORMATION
- - --------- -- Thi ,eutionfohecumnp|e!adb���{i�� --
1.1 Property '
/ � �� Map Lot Unit _
.'._~'~` °�'' '
°/Y Zone Overlay District
Elm St. District CB District
SECTION 2' PROPERTY OWNERSHIP/AUTHORIZED AGENT
- -_ � -___ ___- ____
2] Owner o1Record: 471 kt//tZ13 L/X-/7)/c) tu/9
� � ��� ������
/ �� cu/ront.oi|in�AdUm -- -- -
ii
w�"��~e� Te}epxon� ---' ---
-- /��' � - - ^��"�^�n
Signature - /~^ ,57(e ,_
2.2 Authorized Agent: Steven Silverman
VaIIe�, Home I Inc. P.O. Box 60627, Florence,_ 01062
---- -
Name (Print) Current Mailing Address:
d ` _ �__ __ 584-7522
Signature ' . Teiephoq°
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
__
Item Estimated Cos (Dollars) to be Official Use Only
completed by permit applican
l. Bui!ding _ 4 �� /'�` (a) Building Permit Fee
___ - / uvi/
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee /
4. Ivinchanica|(HVAC)
5. Fire Protection
6. Total =(l + 2 + 3 +4+5) ' 3 �� ChucKNumbo/
This Section For Official Use Only -
Building Permit Number: __ Date Issued: _ ___ ___ _-
Signature: _ _ __- --_-
Building Commissioner/Inspector of Buildings _ Date __ ___ __ '
a
41 w BP- 2011 -0492
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloek: 18G . 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: BUILDING PERMIT
Permit # BP- 2011 -0492
Project # JS- 2011- 000807
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 0.00 Owner: KANTROWITZ RICKI ELLEN
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 41 WARBURTON WAY
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 11/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner