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W err DEPARTMENT OP BUILDING INSPECTIONS 4 Wit________--...-
•
•. 212 Main Street • Municipal Building 7,
Northampton, Mass. 01060 ,4 _'��:
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, N t5okr slf /Gr- ` l/i . k /!LL .Gs't7/Zd/ Ate4 ', c
(licensee/permittee)
with a principal place of business/residence at:
3 `fO /21 / 5 Lb 2 I/i/'Z �a�7/7��n i ; il (phone #) 58 `q- 7ZZ
(Arect/citv/stat ;grip) elgth 0
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:
Acadia Insurance Company WCA5029908 2/1/2013
(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.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that while homeowners who eaaplay persona to do ur.;n+'.,a••ee, construction or repair work on a dwelling of
not nacre than throe units in which the homeowner resides or ea the groin appurtenant thereto art not generally considered to be
employers under the worker's ration Act (GL152, a 1(5)), application by a homeowner for a license cc permit may evidence the
legal statue of an employer under the WoriCer'a Compensation Act
I understand that a copy of this statement may be forwarded to the Departaxat of Industrial Aocibent • Office 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 S1,5OO.00 and/or inxprisonment of up to ox year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against tae.
Signed this / SI day of /7, 20/4 Far dial use only
yJ d Permit Number _
/J
'/ �/ ' , or" ` /' Map# Lot #
Signature of li ., .- • ermittee
} SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not .Applicable ❑
Name of License Holder : S tevenn Silverman_ 077279
License Number
I • • • 07'3 p 6/21/12
268 Forcer R• -• MA Q1 ,_
Address , Expiration Date
584 -7522
Ss• e Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman. 131945 _
Company Name Registration Number
268 Fomer 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 21 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. 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 home in a two -vear 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, on 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
1
OTION S. DCSOMPTION OF PROPOSED WORK (check all applicabld)
f —
New House L: , Addition LI Replacement Windows ' Aiteration(s) 17; Rooting (1
Or Doors ::
Accessory Bldg. : Demolitior2 New Signs : 1 Decks : 1 Siding I I Other
w .,. Pr -. {..., .;.-, 'ir J1".) 1 4 7 07002 Apvl 4 _AA) C hA le A €A IL A_
i
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e....: " ■-zr..t..piotv. g ..11'
ETD. '.., ... t 7: 1: o:
6. If New house and or addition to existing housing, complete the following:
1' '.t ol Du 11 C^c - am ly Ty., ..1
!•,, 1....r: (-.' r, 'I Eh(...t1 '51 y
',.,', l'• ".,'":tftt ft ,i :1:1,7:ClieC:(
't,;(1. tp, •;," titty, ,,,,• Pr, n ut,..t :$n 1 . f'
",` 4 ,: 1 •••". :+! ',. -:`!-", 1
..lf '. tOvtt's., Nu b:: u` $....oc:11
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1 v.: t- :1 C; 1C1
• '›e,: 1 Ar ti' : t 1Cij 1 ,$1.4r.1,:k.so,.... `;$.-1s. '4,, Is ctAtstract m $:, :1 100 .:1 91.;:t.,.$1.-1,:i Ytt, r
; ','Al•n`i f :1;,3 .' :' (it-Itof 1 f)lit
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• St.-1.1,1c - zyik C 1 1y Sew _ _ Pr v..it.i...", %.,, 1 water Sot43 y
1
1 SECTION 7a • OWNER AUTHORIZATION • TO BE COMPLETED WHEN
1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
12)// --nig" e e Or/f 1 6° Y as OPe.-iet ct t. subject pt1y
!'iy , _$ t even Silverman, Valley Home Improvement, Inc.
ri• , 12, i , .., 1 - .0'..tt , t, ..'; 1 to A ,...1$111wiit-.1t l'It$.1::...1 ft rri: dal.' it ...71
....
o*, 0671e ,.„
• ,Stemen_SUaermam, Vail - y_Homia_ImpromementInc_.
i
lic.' dcc r re •,, 7'11: s*,......ttcrric`i'.7› ::riC Iric on tIle forcgcrir g:t;.11.1...Itic .Irri `,. ortj ilc:„.„3,11,t 1:$ '..11 0t . :. u cry
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Steven Silve .1 4 I _
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• Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required b, Zoning
This colu to be filled in by
Buildin 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 KN'W 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 arty proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
•
Department use only
Ti Ci y of Northampton Status' of Pe t :';
Bu ding Department Curb Cut /Driveway Pith
1 2 2 Main Street Sew;rr /Septic Availality
2 � • oom 100 IN /Well Availabil � ' " ',r,
�, sv .. ® - . mpton, MA 01060 Tweets of ctural Plans
AFC °p�,, ° " % 3 587 1240 Fax 413 587 1272 Plot /Site P� '� ,, f
Other Sped 4.` 74
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
87 1 3 w `z,, 7 / xe� Map Lot Unit
7:- 0 4 CZ7 ,q `U 6 2- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
7 i 2.1 Owner of Record: S /� 1.4 ft--/ �
N Ai * 11 G1)l /-611 / u t c � --Y /,_ C ft G /, t%Z/ ate) 2.__
Name (Print) C Current Mailing Address:
.e- 4 Q Telephone ` j z `-
S nature1 - f f L ` �-Er
2.2 Authorized Agent: Steven Silverman
Valle S ome Im•rov -*■-1t • P.O. Box 60627, Florence, MA 01062
Name (Print /i' / ® Current Mailing Address:
/4r 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 / 4 � (a) Building Permit Fee
� l7
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection Co, 6. Total = (1 + 2 + 3 + 4 + 5) C go Check Number 3( .
This Section For Official Use Only (T Q i /�
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
878 BURTS PIT RD BP- 2012 -0923
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 186 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2012 -0923
Project # JS- 2012- 001608
Est. Cost: $6800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 31232.52 Owner: OHOTNICKY JULIANNE D & JOHN R
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 878 BURTS PIT RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE INTERIOR DOORS & TRIM
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 4/24/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner