23A-143 (2) . •
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-css DEPARTMENT OF BUILDING INSPELMONS
212 Main Street ' Municipal Building ,(:-....w.,....7$
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
iik L-6/6 5/7 i // 77 v4-/—_,L,c Y hi % , 2 ?; _,47, ,/bi,
(licenseeipermittee)
with a principal place of business/residence at:
,3 -te,) 1 / piZ / i:),;' ./:),_,I/c! ,777,1,77,4 41/i (phoneil)
(s'tre,eucityh:tatt../zip) „- 4 ' ()
do hereby certify, under the pains and penalties of perjury, that:
V) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
7 .):71 KO 1 :),(6., 6 5 56 /
(Insurance Company) (Policy Number) (Exiiirati'en 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 if neeessa.ty to include information pining 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 hom=0SVDC13 who employ persons to do maintenance, construction or repair work on a dwelling of
not more than three units in which the hotneown,x resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compcasation Act (GL151,ms1(5)), application by a homeowner for a license or permit may evidence the
legal status of en employer under the Worker's Compensation Act_
I understand that a copy of this statement may be forwarded to the Department f Industrial Accidents' Offioo of Irtsuranoo for the
overage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,300.00 and/or imprisonment of up to one year and civil penalties in the form of a Slop Work Order and a
fine of S100.00 a day against me.
Signed this -.) day of fe7 5 2 / b For departmental use only
t Number
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/) Permit Lot#
Signature of LVOnsee/Permittee _
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SECTION 8 - CONSTRUCTION SERVICES
Licensed Construction Supervisor: t i � � S-
A�
— — — t, _h I.c,�J.
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` of Licens ,Holder Steven Silverman _ 077279
5J21/12-
268 �' .JreZ' R d . ;� � t�.1al�ap_tan, _Iii- .__.{11117. __
/ 584 -7522
a' gt a.ure Telephone
I
t Contractor:
.�1Rel;iS�erc,d Home Improvement Not A, N cable CI
SL even Silverman i 1 t G«l
Company Name Registration Numb
268 Farmer Road 1'0/13//
.ci iicSS Expiration Da
I Southampton, MA 01073 Telephone 584- 7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (i .G.L. c. 152, §25C(6)).
t.
j Workers Compensation Insurance affidavit most be completed and submitted with ifs application. k ailure to provide .pus : Dccav,t
wilt result in the cienlai of the issuance of the budding; perm`:t
Signed Affidavit Attached Yes ..... X No 0
1 . - Home Owner Exe
The current exemption for "homeowners" was extended to include Owner-occupied Dwellings of one (1) or two( ?) loon) a''
and to allow such homeowner to engage an individual for lure who does not possess a license, provided that the owne nets
as ssr;acrwistar. C 'IRe78 i. Sixth Edition Section 108,3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he sue reside' or in .nds t,t re :de, o,i illicit there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and or Drill
structures. A person who constructs more than one home in a two-year period shall not he considered a homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that hcfshe shall he
responsible for all such work performed under the bnildin_ permit.
As acting Construction Supervisor your presence on the job site will be reciuired from time to time. during und iil win
completion of the wvork for which this permit is issued.
Also be advised that with reference to Chapter 172 (Workers' Compensation) and Chapter 153 (Liability of Employers t o
Employees for injuries not resulting in Death) of the Massachusetts General l.ai.is Annotated. won faras be liable .'o" porsonts)
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 Gonin° I..asss and State of Massachusetts General Laws Annotated.
Homeowner Signature
A 1-111,0)(
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SECTION 7, OWNER AUTHORIZATION TO iCOMPLETED WEIEN
OWNERS AGENT OP CONTRACTOR APPLIES FOP BUILDING PERMIT
s721
Steven Silverman, Valley Home Improvement, Inc.
7 -,15 7 / 7/C) •
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Steven ...Silverntan, „Val1ey, Home _Improvement, Inc.
Steven Silverzn-
7/2 .././6
Section 4e
ALL Thi"FORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENTED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column . be filled in by
Building D• .artment
Lot Size
Frontage
Setbacks Front
Side L: R: L: 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 /Findi'g ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded . the Registry of Deeds?
NO DON'T OW YES
IF YES: enter Book Page and /or Document #
B. Does the site contai a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a sermit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any sig /s 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 T
City of Northampton :-,
atus o Perm
Building Department Curb Cut /Driveway Permit __
212 Main Street Sewer /Septic Availability_
t
' w�� RO OYI 100 ( W xter /Welt Availability _ —
l Noi'th4mp'i t, MA 01060 Two Sets of Structural Plans
`�Si hone 413 587 Fax 413-587-1272 Plot /Site PIanS__
I
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIO 1 - SITE INFORMATION -- __
Thi s ec ti on. to bap cori ie4 eiTi hi; oaficge, l
1.1 Property Address: s
/ q ,Q / 4 E 51 Map Lot _ Unii
o C criA- o / C9u z Zone __. Overlay District
Elm St. District _ ___ CE District___
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Recotrd: / / q / -E 5'-7
;, _T i )00/6 , q5/t /zo «, "2n ® /C z
Name Prriintt)), —7 Current Mailing Address:
*,_ Telephone 4 34,9- (� �/
ignature ` 9.
2.2 Authorized Agent: Steven Silverman
Valley Home Improver en En- /c , P.O. Sox 60627, Florence,_ MA 01062
Name (Print) / 1 / /Current Mailing Address:
Ae if if 584 - 7522
Signature Te'ephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant __ -
1. Building 15 000 (a) Building Permit Fee
2. Ele ctrical / (b) Estimated Total Cost of
I 5&c• (b) from (6)
3. Plumbing 7S Building Permit Fee
4. Mechanical (HVAC) / ,
5. Fire Protection ,
6. Total = (1 + 2 = 3 + 4 + 5) 1 7 750 Check Number /o3 46 _ 1
This Section For Official Use Only _ l
Building Permit Number: —__ Date Issued:__ _ -_
Signature: _______ — ___ ._ - _ —_
Building Commissioner /Inspector of Buildings Date _._
File # BP- 2011 -0070
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 119 PINE ST
MAP 23A PARCEL 143 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ol 1 /# )� /
Fee Paid Rp V
Typeof Construction: REMODEL KITCHEN
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
INFO 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
Demolition Delay
7/14/(0
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.
•
BP- 2011 -0070
GIS #: COMMONWEALTH OF MASSACHUSETTS
r ' " 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-2011-0070
Project # JS- 2011- 000122
Est. Cost: $17250.00
Fee: $103.50 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:7/30/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 7/30/2010 0:00:00 $103.50
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
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