11A-063 •
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DEPARTMENT OF BUILDING INSPECTIONS
• 212 Main Street~ • Municipal Building
y y SV,
Northampton, Mass. 01060
WORKER'S COMPENSATION DiSTJRANCE A.N'FWAVIT
(licensee permittee)
with a principal place of business/residence at:
3 /21 / � /'Li / ,,,/ r 4 /t ` : (phone #) �8 `/
(sttr- t/city/rt2 ; /.7ip) C 0
do hereby certify, under the pains and penahi es of perjury, that:
) 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 C:onapary/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Cor rpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Corrpany/Policy Number) (Expiration Date)
(attach a +dditicaal sheet if necessary to include information pertainia.g to all contractors)
( ) I ana 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 who employ pan= to do maintenance, construction or repair work on a dwelling of
not more than three units in which the horrsowner resides or ca the grounds appurtenant thereto are not fatly considered to be
employers under the sweet's lion Act (GL152as 1(5)), application by a homeowner fora lice cc permit may evidence the
legal clams of an employer under the Worker's Compe atioa Act
I understand that a copy of this statement may be for wardc3 to the Department of Industrial Accidents' Office of Insurance for the
covera verification and that failure to secure coverage tender -°elioa 25A of MOL 152 can lead to the ikon of aintinal penalties
conaisti ag of a fine of up to S1,300.Q0 near imprisonment of a.tpla one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.013 a day against tne.
7 r
Signed this /=' day of For departmental use only
MaP41 Lot it
> Permit Number
Signature ofL ; .,ensee/Permitt ee
•
/143 J / f;
fice Consul and IltisiriessRegulation
10 Park Plaza - Suite 5170
13ostori, Massachusetts 02116
Home Improvement Coritra(„...t(ir Registratioti.
Reaistratior1. 131045
• Expiration: 10/13/2012 Tr# 204530
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD,
SOUTHAMPTON, MA 01073
1. pdute Address aud retitrit tar&L Niat:k r for ciiiitige.
Atfdress Etrifiloi, went ht Card
04 KY
offiv.eoiconi,`,;;;;e;„4:ifiic!-;.<11't?,i;11.,i:.;);;;4.'t,i';'7ii7'..;, License or registration i alid Iii r irtil.i1:1111
HOME IMPROVEMENT CONTRACTOR liefiire tOe expiratititi iLite. If found return to:
Registration: 131245 Type: Office of Coifs:tuner Affairs and Rune :sii Resolution
Expiration: '1/013/2012 rvuaI 10 Park Hata - Suite 5170
11.4 \1 02114
STEVEN 51,,VERMikr1, Ly
248 701
SOUT1-4, MA 01073 .
1:11:1ellccrct:..try et valid
Const.ruc
is 77279
Restr$ctotiv:-:. 00
STEVEN A SILVERMAN
268
SrIUTHA!MPTC)l, 0137„:"
,:„ 6,t21i2912
r 26558
,„4”‘Cf+'
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SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Appiicabl ❑
Name of License Holder : Steven Silverman____ 077279
L �enso Number
268 F e r , o a e S- outhamp t pan ,- _MP 01073 6/21/12
Addre Exp:raton Date
( 584 -7522
s r ;n rture Telephone
9. Registered Home Improvement Contractor: Not ,Af plicab e ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer _10/13./2-
- ..-
Address Expiration Da to
Southam ton, MA 01073 Telephon €; 584 -7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with tf:s application. Failure to provide this afticavt I
will result in the denial of the issuance of the building permit. I
Signed Affidavit Attached Yes )xl No 0 I
11. d ome Owner Exemption
The current exemption for "homeowners" \vas extended to include Owner--occupied Dwellings of one (1) or two(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. CMR 780. Sixth Edition Section 108.3.5.4.
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 -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she 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 fbr which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of F.ntployers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable coi person(s)
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 of
Northampton Ordinances. State and Local Zoning; Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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'C'TrON DESCRipT ION' or pRoposro vionk_cchttr.;:„1112,01
Vi'ir.cicv,!. A , Roof irr,
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OATH gi€Y irrott3 (Poi? Pmcz ro
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6.1 If Ne house and or addition to existing 110USillg... complete the following.
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SiCTCI 7a - OWNER AUTI IOREZATiON TO £3t COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR API u:s FOR BUILDING PrRmir
Steven Silverman, Valley Home Improvement, Inc.
•
2 /1-s-"2-e/&//.4-
Steven_Siiverritan, Valley _Hone_ Inproverttent,_ Inc .
Steven Silv an
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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
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 /Findin /ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at t - Registry of Deeds?
NO DON'T KNO ' YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brisk, body of water or wetlands? NO DON'T KNOW
YES l
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:
r_CE VED .
LJAN 1 2 2012
Department use only I
City of Northampton Status of Permit: I
�. Building Department Curb Cut /Driveway Permit
212 Main Street Sewer /Septic Availabil
Room 100 Water /Well Availability
Northampton, MA 01060 Two Sets of Structural Plans 1
phone 413 - 587.1240 Fax 413-587-1272 Plot /Site Plans:
Other Specify 1
l
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I
SECTION 1- SITE INFORMATION
This section to be completed by office
1.1 Property Address: /
62 /e1 e---/a/A1 f/v Map Lot_ __Unit
Zs /vd C%_C 3 Zone_ __Overlay District .___
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 3 f 4�)/6 e mi
Name (Print) 7� Current Mailing Address:
) -4 1 )/ 1 144<a Telephone 5 z L(G / - 6 7?
Signature J
2.2 Authorized Agent: Steven Silverman
Valley Home Improveme , Inc. P.O. Box 60627, Florence,_MA 01062
Name (Print) 7L/1 Current Mailing Address:
//if Ai 58.4 - 7522 _ _ __ __ ______
Telephone
Signature ele
g T p
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant I
1. Building (a) Building Permit Fee
J (X7/0
2. Electrical (b) Estimated Total Cost of
J 6J) Construction from (6)
3. Plumbing / t) Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) (0) 5CD Check Number ) 9� 3 v `
This Section For Official Use Only
Building Permit Number: Date Issued: __
Signature: _
Building Commissioner /Inspector of Buildings Date v i
File # BP- 2012 -0653
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 63 EVERGREEN RD
MAP 11A PARCEL 063 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3
Fee Paid
Typeof Construction: REMODEL BATH
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
INFQRMATION PRESENTED:
i/ 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
77
Signature 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.
63 EVERGREEN RD BP- 2012 -0653
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11A - 063 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 -0653
Project # JS- 2012- 001123
Est. Cost: $6500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 11543.40 Owner: MERRIAM MARTHA A
Zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 63 EVERGREEN RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:1/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH
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 1/18/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner