24A-021 4 - tiAMp7
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DEPARTMENT OP BUILDING INSPECTIONS __` f
• 212 Main Street ' Municipal Building
Northampton, Mass. 01060 �'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, ,V L5 o,U 5'H i G1% 4_Z._/i // 1 1=; 2 aa IS T, ill L
(lip)
with a principal place of business/residence at: .
3 go ) 5 1_6 a i ), i/'z Vat./ -2ti %r , fiM (phone #) 58 '/- 2 Z2
(strert/city/sttate / zip) ad 6 o
do hereby certify, under the psins and penalties of perjury, that:
IX I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Acadia Insurance Company WCA5029908 2/1/2013" ,
(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 ifneccsiaryto include information pertaining 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 homeowners who employ persona to do maintenance, 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
employers under the worket's ration Act (GL152,ss 1(5)), application by a homeowner for a lionise or permit may evidence the
legal statue of an employer underthe Wodter'e Compensation Act.
I understand that a copy of this statement may be forwarded to the Deportment of Industrial Accidents Moo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting 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 Wort Order and a
fine of 5100.00 a day against ma.
Signed this . / $ d a y of / 20/4 For depZrt 1 t ere only
Permit Number
I / ' .,1 Al ` ,aiu. Map# Lot #
Signature of L'� .• - • ermittee .
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Stel_en Silverman _ __._ 077279
License Number
268 Fomer Ro d, outhampton, MA 01(173 6/21/12
Address /u\ Expiration Date
584 - 7522
Signature ` Telephone
9. Re Home Improvement Contractor; Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Forcer Road _ 10J13//2
Address Expiration Date
Southampton, MA 01073 Telephone 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 E No ❑
11.:- Home Owner 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. CVIR 780, Sixth Edition Section 108.3.5.1.
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 l53 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von may be 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 Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
t !
• I;CTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
1
1 .
1 ,. New Hout.e L: 1 Addition 0 Replacement Windows ,: Aiteration(s) C 1 Rootinc p
' Or Doors r..]
Accessory Bldg. ,3 , Demolition4 New Signs : 1 Decks ; ) Siding [ ] Other : I
€ !
- ..., ,.. _ , ....
,
Bic De'IC'us on r f No.i., ?t Fct GARevst: ' RE UDF1,korvq" , POireltoi; DO:Pilb Lmiks 'N 13AStroki4
P(s Ok '.:■,
hrir:rom Y.L. No np, ntv neci `te. Ne;
: Att.o.,heu Narrallvt Perr.errolx-R , ,Erfinit.hcf...1 '...ni,t•.nl E ()' 0 -, i4 )
Plar ttachod Rol! Snot7t.
63.1f New house and or addition to existing housing., complete the following:
, ...: Use DI htploing : One : am Ey Two ramtly
i i
t; f',LnItri,er ol rc.0' s .n each 'ar ,rri[t: Niv f,T iiF.11
If, t-efe n c.„1 alachee
1 ;.1 ry.,er.; SQuore Icc.,taKe r:I. new „c.
''... 7•1 :
. YelhOi of hc..1,,rri..C1 1'i-tr. ^,,I.‘, ;:it '■Vce<1‘,.. Nu-I; r.f u' t.,:octi
, 2 F - ,er gy Cc7servcn Cor ie IVchcck Enc-gy Corn...)11 form 8:tackm?
l <1 cc',f,ittiction
• '..co'rAr. w 1001 :A , ,,et- - 14)(1.f,? '1'es `kl Is unistr Oct ..)n w,-,t :00 yr . 'Ilc:1rlarr
1' ...);If,ernent ,:',!' celNif Irz,of helcA, .e i
zoo idir F c c . . f r -11 l',0 .Le 1.3tplcmp, ,'d 2 rCt.:latie" f",.?
• StpliC 7 e!III, C'..v SeWf7. Pr , N,31e %-•.':: City water SoDP Y ____.
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
MA IAA L-4._ , , ., ,, , • as Owner cit subject pr3pEity
he-C!.by .:litnnri7e. _Steven Silverman, Valley Home, Improvement, . . ,. Inc. , . _ ,, ., „ :o a:t On
rily bc Of w ;JA riitUvt, -r.;::,,ittil: W % ..)1k i711,1thWIZ . bji mis t),,11 Cl IIR r7A a :4)11Cit t ICs
ifikra:Jr crl Oe ler :).)te — -
• _Steen Silyerman, Valley_nome_Improvements _Inc . , as r...;:wher/Authrrriefl AEerit
he-eby dr.c!are 'Staterne.!)ts Niti inforr”itti:dri un thu forcRoir - F, .1;)[: crt l'ut". ortd iiecur,lte, t ".tie bt 1)1 cry
krcv,lecge and belief.
St,7, :"Cc• ".1 2F1 E,•
,
Steven Silve z. • /
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ni 0 .2.. -ie
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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.hy
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 ev= 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 br• sk, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permi been or need to be obtained from the Conservation Commission?
Needs to be obtai -d Obtained , Date Issued:
C. Do any signs exis . on the property? YES NO
IF YES, descr'.e 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:
1. .-'t "�l e'
�.' Department use only
ity of Northampton Status of P i,t. - ,
Z ` ZO�� ilding Department Curb Cut /briV,eway it �
0 12 Main Street Sewer /Septic Availatl y
00 Room 100 W / Well Avai : .
�gi °1 ' Northampton, MA 01060 b of tural Plan
phone 413-587-1240 Fax 413 - 587 -1272 P %S ets te P � e s '',1'': F
O ther; Spec! ,.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
A
1.1 Property Address: This section to be completed by office
� r
' l8 l,Ar (,i46bizR'( L- l l i� l Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
iii>o Y HO— LI 6 Btric 1-Aty
Name (Print) Current Mail 6 ress: 07 i 7
Signatu
L
Telephone
e
2.2 Authorized Agent: Steven Silverman
Valley Home Impr vement,, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) .// Current Mailing Address:
584
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $7 5 cx (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) - i j 5Co Check Number C YG cie3 $5 s
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0849
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 45 BLACKBERRY LN
MAP 24A PARCEL 021 001 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 1 �.r/�r
Fee Paid X6 y��lJ
Typeof Construction: REROOF GARAGE & FRONT PEDIMENT,DEMO WALLS IN BASEMENT FOR
PERIMETER DRAIN
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
INFRRMATION 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
c._
r(
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.
45 BLACKBERRY LN BP- 2012 -0849
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0849
Project # JS- 2012- 001494
Est. Cost: $7500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 10018.80 Owner: HALL MARY F
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 45 BLACKBERRY LN
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF GARAGE & FRONT PEDIMENT,DEMO
WALLS IN BASEMENT FOR PERIMETER DRAIN
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 4/3/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner