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Valley Home Improvement, Inc. Robin
3 40 Riverside Drive, PO Box 60627, Northampton, MA 01062
TITLE: Bath
Office Phone 413.584.1522 Fax 413.585.0820
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Find us on the web at : www.ValleyHomelmprovement.com
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. The Commonwealth of Massachusetts
- -- Department of Industrial Accidents
P te /
1; = 1 ' : Office of Investigations
_,. y 600 Washington Street
• Tad= i` Boston, MA 02111
• T www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/lndividual): Valley Home Improvement, Inc.
Address: _ 340 Riverside Drive
C ity /S tat el:Zi, Northampton, MA 0106- Phone #: _ 413 -584 -7522
Ar you an etnployer? Check the app ro;?elate box: Type of project (required):
1. [ I am a employer with 4. El I am a general contractor and I
12 — 6. ❑ New construction i
lnvv -c (full anrilnr part- time). "` have ta the suo- Contract NS
2. E] I am a sr le to onrietor or partner- listed on dm aiiaLiicd sheet. ?. ❑ Remodeling
ship aril have no employees These sub contractors have 8. ❑ Demolition
ki> for me in any capacity. employees and have worke:
wor
S Y 9. ❑ Building addition
#
[No workers' comp. insurance comp. insurance.
required_] 5. ❑ We are a corporation and its in rl F)Prtrirn1 repairs or additions
3. [] I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself, m se' . right of exemption per MGL
Y [No workers' comp. 12.0 Roofrepairs
.-. „i 1 t - c. 152, §I(4), and we have no
°. -` -' - - -
. employees. [No workers' 13.0 Other
comp_ insurance required.]
"Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information _
t Home_owners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
1 Contractots that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employes, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. .
Insurance Company Name: Acadia Insurance Company
Policy # or Self -ins. Lic. #; WCA5029908 Expiration Date: 2/1/2013
Job Site Address: City /State/Zip: .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 7/
I Date: ,
/
Phone e:
i
O fficial use only. Do not write in this area, to be comp by city or town officiaL
City or Town: Permit'License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cify /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
l
Contact Person: Phone #:
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I SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not App'icable
Name of License Holder : Steven Silverman ____ 077279
License Number
268 F•mer Roa• , ...5_outha npton,.._MA n7 073 ___ I 6/21/120
Address j Expiry of Date
ii
584 -7522
Signature Telephone ff
9. Registered. Home improvement Contractor: Not ,Apal cable ❑
Steven Silverman. _ 131945
Company Name Registration Number
268 Fomer .Road — — — — _ 10/13/L2-
Address Accirss Expiration Date
South ton, MA 01073 Telephone 584 -7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (It+1.G.L. c. 152, §25C(6).)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afficiavit
result in the venial of the issuance of the building permit.
Signed Affidavit Attached Yes....... >x1 No I
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or fwwe( 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 "80, Sixth Edition Section 10S.3,5.1_
Definition of Homeowner: Person (s) who own a parcel of land on which hclshe 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 limn
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 he
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 of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be li ble @car persons
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
• TCT:Cti DESCRWTION s Pr3OPOSED vcr
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SECTION 7 OVVNER ALITILORiZATiOri TO ac COMPUTED WNEt4
OWNERS AGENT OR CONTRACTCR ...&,?PLIES FOR BUIL DING PCF..1i
X//NI .
Steven Silverman, Valley Home Inprovenent, Inc.
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed R: quired by Zoning
T is column to be filled in by
uilding 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 /Fin. ng ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded a the Registry of Deeds?
NO DON'T K SW YES
IF YES: enter Book Page _ and /or Document #
B. Does the site contain a . ook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a per t been or need to be obtained from the Conservation Commission?
Needs to be obta' ed Obtained , Date Issued:
C. Do any signs exi on the property? YES NO
IF YES, descr .e size, type and location:
D. Are the e any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
MOO: qlYl
Department use only
Fa . , 202 Cit of Northampton , of Permit:
:Lill Z ing Department Curb Cut/Driveway Permit
2 Main Street Sewer /Septic Availability
- ' of Room 100 Water/Well Availability •
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot /Site Plans;
Other Specify__ •
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
`f i #)M J % Map ______ — Lot _ - -Unit
A / 6e /7/y ,/ //7// `66 G) Zone _ Overlay District ___
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: `,/ /1,7.4) i✓ S
/ /�i / Csl 6' 0
% (7 Y /tl 3 / S G /( r X / - " S[ /P1 ,s 6/,<. A, o,-'LTI /7 r
Name (P )) Current Mailing Address:
Telephone
2.2 Authorized Agent: Steven Silverman
Valley Home Improve t, Inc. P.O. Box 60627, Florence,_, MA 01062
Name (Print) Current Mailing Address:
_ 4 _584 - 7522___ _- __
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant ,
1. Building / 5 ( (a) Building Permit Fee
2. Electrical 1 CZ2) (b) Estimated Total Cost of
Construction from (6)
3- Plumbing 4 J Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) / 7 506 Check Number 0 } j0,7
This Section For Official Use Only
Building Permit Number: _ Date Issued:, _ __._..
Signature: _
— - - _____ _
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0689
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 4 LINDEN ST
MAP 25C PARCEL 201 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out n 9/ a - '/ 5-
Fee Paid oG
Tvpeof Construction: REMODEL 2ND FLR 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F 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
Der.. . ori.: ay
,...._ 3 ,... o_____
Si : ui .., g 0 ici. 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.
4 LINDEN ST BP- 2012 -0689
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 201 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 -0689
Project # JS- 2012- 001208
Est. Cost: $17500.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 9539.64 Owner: RUSSELL MICHAEL J C/O STACY ROBISON
Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 4 LINDEN ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:2/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL 2ND FLR 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 2/3/2012 0:00:00 $105.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner
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