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CW DEPARTMENT OP BUILDING INSPECTIONS , -.1;-. ` _ f
212 Main Street ' Municipal Building
14 to "V
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, /i/ L50 AT Si' /i''l =t 6/"i - 1 ///7-1- %/ //O e_ .G;->i/ ‘45 1 /;1;1
(license&Jpermittee)
with a principal place of business/residence at: .
3 'to /2l // $ i .6 2_ ✓'Z j A /O,o2/ir/V/ ; '//f (phone #) 8 q- 7' Z2
(stre t/city /s zi ip) i wo 6 0
do hereby certify, under the pains and penalties of perjury, that:
1 am an employer providing the following worker's compensation coverage for my
employees working on this job: .
,SZ4 44 SS' Li/S: GU . W C 76 l 5 / ./ / //l
(Insurance Company) (Policy Number) (Expiration Date) .
( ) 1 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 if necessary to include information pertaining to all contractors)
( ) 1 am a sole proprietor and have no one working for me.
( ) Ian a home owner performing all the work myself
NOTE: please be aware that while homeowners who enaplay persons to do rr*a intrna nM, construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employes under the worker's compensation Ad (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 Act
I understand that a copy of this rtet ,t may be forwarded to the Department of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the ikon of criminal penalties
consistirtg 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
Imo of 5100.00 a day against ran.
Signed this /3 day of / 2 & e el For depS ZZ t use only
M ei, A Permit Number Lot #
Signature oft.f Permittee { 1
� •. 1t.ss
' Massachusetts Department of P ublic Safety 1
Board of Building Rc��ul.ctit >ns and 5tantfai ads
`,. Construction Supervisor License
1
License: CS 77279 1
Restricted. to: 00 � I
r y N
STEVEN A y SILVERMPN k 1 i
268 F.OMER.RD r " R
SOUTHAMPTON,' MA 01073 =i • 1
Expiration: 6/21/2010 I
aim- '' Try`: 25795 /
( un7p7igsioneY - -
•
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B6 or Allciicagaegu7Cii +crAas4d99tgvf+t ife0 License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
=. e i
Registration: 131945 Board of Building Regulations and Standards
Expiratibnr, 10!1312010 Tr# 275412 One Ashburton Place Rm 1301
V Type Individual Boston, Ma. 0210
;
8 � �
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STEVEN A 51LVERMAN ��
STEVEN SILVERMAN L �/ A �// r r ,/f y _ , 268 FOMER R0. _ _ - _ Ca�.g...Cb . ` / P t• \• J. lclr.�'f �. ,
SOUTHAMPTON, MA 0 - Ad 'Not valid without signature
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SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Bolder : Steven Si1 re 'man_.__ 077279
License, Number
268 Fomer Roam, _,.,.uthampton, - _ MA 01 073____ .. - 6/21/10
Addres / r Expiration Date
1
584 -7522
S i -n / e . Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven S i lye r tta.n 131945
Company Name Registration Number
268 Fomer Road 10 /13 /M
Address Expiration Date
Southampton, MA 01073 _._ Teephone 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 this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
1 . - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner-occupied Dwellings ofonc (I) or t\Vc(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner nets
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land an 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 ands or farm
structures. A person who constructs more than one home in a two -`year period shall not be considered a ltonteo ner.
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, on may he liable for 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. C ode, Cry of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts Cenral Laws Annotated.
1 lotncowner Signature
' ,,.,.. DESCRIPTION OF PROPOSED ViORK Ceitil.1 All .:TnjiIiI0
.........., ,.. „ ,...,. .. , ,_
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Nitw He Etn.t.t '....: I Aedition 1 Replacentegt Windaws ktelation(L) I: ' Roof inn I
Of Coors - >c
AcCESSOrt Bldg. ::..I Dermolitio New Signs ' 1 Decks ; I Siding I j Other ,. I
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6.i, If New house and or addition to oxistiLgt housitig. complete the following:
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: SECTION 7a - OWNER AUTNCRIZATION - TO UE COUTLETED Wilet,I,
......
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I
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Steven Silverman, Valley Home Improvement, Inc. :: -, T. LI
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Stemen—Silmerman,__Malley_Home_Impromement.Inc— „i '7. ....,. 1,- ,- 1 AL",,t
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stn Silvermma
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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 /Finding ever been issued for /on the site?
NO DON'T KNOW ,�' YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis y of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, bod of water or wetlands? NO DON'T KNOW
YES -
IF YES, has a permit been o'need to be obtained from the Conservation Commission?
Needs to be obtained J 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:
Department use only
' City of Northampton Status of Permit:
' ' BLNIding Department Curb Cut /Driveway.Permit
2\2 Main Street Sewer /Septic Availability
` Room 100 Waer /Well Availability
rthampton, MA 01060 TwdSets of Structural Plans
phone 413- 587.1240 Fax 413- 587 -1272 plot/Site Plas 5 -.
Other Specify!
)PPLICATION 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
// /' / / J S j Map Lot Unit
0 (5706 z_ Zone Overlay District
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: // y // /1
L a /-f /mil >,`' rZ C , fn z; L %z
Na - P� / Current Mailing Address:
Telephone
'gnature
2.2 Authorized Agent: S teven Silverman
Valley Home Improvement P.O. Box 60627, Florence, MA 01062
Name (Print) / Current Mailing Address:
584 -7522 _ —__—
Signature V Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � rr - (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _ � ���
6. Total = (1 + 2 + 3 + 4 + 5) ' 1550 Check Number `35
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
119 PINE ST BP- 2010 -1156
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 143 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 -1156
Project # JS- 2010- 001691
Est. Cost: $8550.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 18469.44 Owner: BUSH JANET & BOOKER
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 119 PINE ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :6/18/2010 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: nK 612.51 C `
Wit KEW, CARL. — I/A i ri) trt - CM( K
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
1444 Am itos44.4
Certificate of Occupancy 6125 !d Le / ignature:
FeeT_ype: ate Paid: Amount:
Building 6/18/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo