24C-105 (2) A:,. Massachuscttti ijcpartmcnt of Public 5aFet)
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4 Qoard of guildin
Rc�n�tations and Stanil:ti•t
Co Supervisor License
License: CS 7727 1,
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Restricted to w
STEVEN A : SILVERMAN
268 FOMER RD y
SOUTHAMPTON, MA 01073
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Expiration: 6/21/2010 l i
q:. -G•— '—' - T r#: 25795
t' ummiss i 1,ncr •
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8c7,, o yikli egr+ui;aps a j iR5Ffi'fiexi' ° License or registration valid for individul use only
' HOME IMPROVEMENT CONTRACTOR re.
B Board o the f Building ation Regu If found and Sta rn to:
Registration: 131945 One Ashburton Place Rm 1301
1� Expiration 10/13/2010 Tr# 275412
Boston, Ma. 02108
` Type Individual 4
STEVEN A. SILVERMAN
STEVEN SILVERMAN �� ( / r /,�j
268 FOMER RD ! ! � f % f` <�i.` —_
SOUTHAMPTON, MA 01073.. - Administrator i�1ot valid without sig
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�` DEPARTMENT OF BUILDING INSPECTIONS , - _Y
212 Main Street • Municipal Building = s �
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, /(k'LSOkr 5%1/ /9%`Li/ !///z- y /foriL .Gt�l�/' / //Lfi7 , L
(licenseelpermittee)
with a principal place of business/residence at:
3.f6) / e j12_45 i.b �/Zil //4,42 r7"/ - 0/Z; /1 (phone #) -8 - %ZZ.._
((eet/city!s atP /zip) B /Ov 0
do hereby certify, under the pains and penalties of perjury, that:
(X) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(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 shoot if necessary to 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 whilo homeowners who employ persons to do main trnant -c , construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's lion Ad (GL152,ss l (5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act.
I understand that a copy of this ctatomcnt may be forwarded to the Department of Industrial Accidents' Ofoe 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 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
fine of 5100.00 a day against tae.
Signed this / /
, day of G`�e /'/ For use only .
id „6 /41 , ,,> : 7;?-' Permit Number ` ., Mats# Lot #
Signature of L g 'ermittee
,
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not A,pp'iicable
Name of License Holder :Stevenjlverman_. —_ 077279
L;r_ense Number
( 268 Fom- Roa• S• ,.t. -,, • •n, MA o1073 __ _— 6/21/10
Address I Expiration Date
584 -7522
•
Slgnat e Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman_
Company Name Registration Number
268 Fomer. 10/13
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 lh s application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ffiI No ❑
11. - Home Owner Exemption
The current exemption for ''homeowners" was extended to include Owner- occupied Dwellings of one (I) or tv o(2) families
and to allow such homeowner to engage an individual Far hire who does not possess a license, provided that the owner acts
as supervisor. CMR 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 lroute in a two -veer 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, 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
CTIC N, DrscRi pilot,: or PROPOSED ' t.'+3R K2IChk U P';
NOW ItC11:,t.„: AtAlitiOrt J ReplacemeA Vt'ir,c1cwf. A terit1() Roct IN:
Lif Coorf. :
AccEs.sory BEdg. Derwiitior New Signs 1 Decks SAirg )([ Other I
r • plActinuvr CI,APBoARt tqpi - 64E c
° Y - ' 14147152. filA
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62, If New house and or addition to existing housing. complete the followingi
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SECTION 7i - OWNER ALITNORIZAMN - TO OE COMPLETED WIZEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR 61)1E011'4G PERMIT
,4
Ls,
Steven Silverman, Valley Home Improvement, Inc.
reV11/ - Get"- a0 7 4,2 .2/ 0
:317,
, ate3ten_Siaxerman,......Nalley__Hoxfte_Improy...erftent,__Inc, t
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Steven Silverra- _
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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 Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there ally proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Department use only 1
City of Northampton Status of Perrriit:
Building Department Curb Cut /Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water /Well Availability
Northampton, MA 01060 Two' Sets of Structural Plans
phone 413-587-1240 Fax 413- 587 -1272 Plot /Site Pla
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE,IOR'DIM 6tJS,kA CIE OR TWO FAMILY DWELLING
a 2 4 2009
SECTION 1 - SITE INFORMATION
1.1 Property Address: ,This sggion to be completed by office
/ .3 /11//5$ _____. L t Unit
l► �
�/ � O 77"/ ! � 27,/0/Z 1/ el/v6 Zone Overlay District
Elm St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: rrc)3 / 5 / j S7
Name (Print) �/h Current Mailing Address:
I 71.,./-//&k," Telephgoep 4i
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a(6 4. /ti
2.2 Authorized Agent: Steven Silverman
Valle Home II ,•rovem- t �,./ P.O. Box 60627, Florence, MA 01062
Name (Print) j Current Mailing Address:
,,, r ,� 584 -7522
Signature ' / ` Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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) 2 Check Number 0764/5( 35"-
This Section For Official Use Only
Building Permit Number: Date Issued:_
Signature:
Building Commissioner /Inspector of Buildings Date ____. 1
103 MASSASOIT ST BP- 2010 -0322
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 105 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 -0322
Project # JS- 2010- 000431
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 14331.24 Owner: FLEISHER A NICHOLAS & PHOEBE M
Zoning: URB(1001/ Applicant: VALLEY HOME IMPROVEMENT INC
A7: 103 MASSA -1 ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :9/24/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE CLAPBOARD SIDING
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: ® K /D' oZ 6 '49% -
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULAT 1 NS,/
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Certificate of Occu. anc �//■ Si! nature:
FeeType: Date Paid: Amount: r ,y»
Building 9/24/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo