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Cw � *�' DEPARTMENT OP BUILDING INSPECTI
• 212 Main Street ' Municipal Building
or Northampton, Mass. 01060
WORKER'S COMPENSATION DiSURANCE AFFIDAVIT
/ LSo.U � H / G -L� j _ j // / L't7t ,. ' /' /rt ii, _?-7
(licensee /permittee)
with a principal place of business/residence at:
3 -to // dZre S ;:b Jr4 /✓'Z 2)/1 ,eM (phone) f- 8 `f - Z/
(st eet /city / sta tip) efid 6 0
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
/i 4/ 5S 7 //5.. GO . Lt C g6; 6 556 cs 1 7.
(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 ifnecessary to include information pertaining wall 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 who employ person: to do maintenance, coosuvction or repair work on a dwelling of
not more than three units in which the homeowner resides or oo the grounds appurtenant thereto are not generally considered to be
employers under the worker's lion Ad (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Works Compensation Ad.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidraia Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fax of up to $1,500.00 and/or imprisonment of up to one year and civil penalties in tine form of a Stop Work Order and a
fine of 5100.00 a day against me. rY ,-
Signed this /5' day of / 44 .&el For departmental use only
Permit Number
',. ,; 4 Map# Lot #
,
�... tiias .�ehtasctt`; Dep of public 5.t #et+ l I\
•Y, na1 tions and Stn d0.rds
" �I'!, Board of Buildin * R c�
Co Supervisor License
u 7727 1
License: CS xtillti ti,:Y,
Restricted to . 00. ti ; l 1
I
STEVEN A SI `t ; �.; 1 •
268 F.OME#a.RD ,r y . lit: "x
SOUTHAMPTON,' MA 01073
1
i
Expiration: 6/21/2010
o jL �-y Tr#: 25795
oullgl l >;r:iuner
•
B o{' yiidi;agnite.gd.aii d geal('t rcf D icense or registration valid far individul use oniy
H OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards ,
R eg i s t ra ti on: 131945 One Ashburton Place Rm 1301 � '
Expiration:, -
�;� � 10/13/2010 Tr# 275412 Boston Ma. 02108 - / V
,,� Type Ind ividual 0
STEVEN A SILVERMAN`
STEVEN SILVERtv1AN j ; 1/74 /� V1//T./7/64----
f
268 FOMER RD. t- - - ♦b..4C) -a �-�_ �.!(. f_ l -. 1. l
SOUTHAMPTON, Mk- 01 073. -: Administrator '('Jot valid without signature
f
4
•
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C
r —
SECTION 8 - CONSTRUCTION SERVICES
_� 1
.1 Licensed Construction Supervisor: Not Applicable El
Name of License Ho Wcr
St -yen Silverman_ _--- - - - 077279
Lcense N
268 Fo ...d :_o�.tthamptfln,._1+� n'1 n73 6/21/10
._ . I
Address j I E cplraso,� Dave
584 - 7522
S ' / ' Telephone
9, Registered., Home Improvement.- Contractor: • Not Applicable ❑
r Steven Silverman_
I 131945
Company Name Registration Number
268 Fomer Road __ 10/13//
Address
Expiration Date
Southampton, MA 01073 Telephone 584 - 7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit a
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X No 0 1
1
:1. - Home Own Exemption
The current exemption for "homeowners" - was 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 105.3.5.1.
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 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 liable for 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.
> lomeoavner Signature
•' DEI5CMPTIpN Q1'
A :j:
Sigr di;FACIhej
51 4- r-e- roof A IiirA?6 7 ,Sq (44rt)
6,3, If New house and or addition to existing housing, complete the following.,
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4 1.
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'" • 4 ; '44 i '4 '4, '8',.14:".
4.: 4.;c", ". % "1 y
SECTION 7, OWNER AUTPIORIZATIOPI - TO GE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/77 0 ‘— •
Steven Silverman, Valley Home Improvement, Inc.
iL \ 7 k Z
S teven_.5 i rman Improvement,__Ine ,
':1 r • ,
7nr
M:11
Steven Silverman /
//
d/2
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 /Finding e er been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the 'egistry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a bro. , body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit •een or need to be obtained from the Conservation Commission?
Needs to be obtain =d Obtained , Date Issued:
C. Do any signs exist n the property? YES NO
IF YES, descri size, type and location:
D. Are ther any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
f ,
.
Department use only I
!,.- ,City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit —
2009 212 Main Street Sew
.1 er /Septic Availability
CA 2 oom 100 Water /Well Availability
' Norkham1ton, MA 01060 Two Sets of Structural Plans
phone :0-,,5_13:1,,..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
/C' at,4 a ity/, .s
Map Lot _ Unit
, I7/9 a/o(PD Zone _ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
9i , 40 /,7�D P 5.i
.7 b 1 7- ,acz ,r✓0A- L7717y- ,oiz,U ,' 6"/60 2--
Name (Print) , Current Mailing Address:
'/ (" \ (l* \ j L Vt t ( Telephone
Signature 576 — 2_/ f U
2.2 Authorized Agent: St even Silverman
Valley Home Improvement P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address:
J%/ / .__. 584-7522_ _. _ ____
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant .
1. Building 41 9 3U7 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee i
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 = 3 + 4 = 5) i t, 3(,q) Check Number 014 1 5d %
This Section For Official Use Only
Building Permit Number: Date Issued:_ __
Signature:
Building Commissioner /Inspector of Buildings Date
46 WINTHROP ST BP- 2010 -0476
GIS #: COMMONWEALTH OF MASSACHUSETTS
- ap tioek: 38D - 080 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-2010-0476
Project # JS- 2010 - 000657
Est. Cost: $4300.00
Fee: S35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 9016.92 Owner: POWELL JEANNE A & JUDITH POOL
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 46 WINTHROP ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:10/29/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE DET GARAGE ROOF
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 10/29/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo