Loading...
12C-046 (3) O ,ItA1HP lO e,, Gitg of Northampton -* B Vii. Vi r� lasaz scknsetts _ = ` �- DEPARTMENT OP BUILDING INSPECTIONS 4 q ` 212 Main Street 'Municipal Building ' . Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, , sLSOAr it hl%W7 1 l/.9 -'-LP' //0/11 vs e4/, J L (licenseclpermittee) with a principal place of business/residence at: 3 `•0 /<11/__,-.5 Lb 2 i)nli / � /a,e-/7fnt.r7i�ia/l; lid (phone #) 58 ¥- ZZ. (str=t/city /s',ate/zip) NO6 0 do hereby certif under the pains and penalties of perjury, that: 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 Comrpany/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet ifnecossary to include information pertaining to all contactors) ( ) 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 persons to do pr. 4 +t••+ *an, construction or rcpair 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 worker's oc ration Act (GL152 ss 1(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 stam:nem may be forwarded to the Depertmcad of Industrial Accidents' Office of Ixnuraoce for the coverage verification and that failure to secure coverage under section 25A of MQL 152 can lead to the imposition of criminal penalties consisting of a fine ofup to 51,500.00 and/or imprisonment of up to one year and d vii penalties in the form of a Stop Work. Order and a fine of S 100.00 a day against me. Signed this . / _ day of ii-4 201& For departrentel use only Permit Number I • J�1I ` /it¢a. Map# ,Lot # Signature of IS.. - • ermittee - 6:79 t t.,941424‘itrwA , ley Office of Consumer Affairs and Business Regulation \lit; 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 131945 Type: Individual Expiration 10/13/2012 Tr# 204590 STEVEN A. SILVERMAN STEVEN SILVERMAN 268 FOMER RD. „ SOUTHAMPTON, MA 01073 Update Address anti return card. Mark reason for change. Address ' Renewal fl Employment 1 Lost Card 50M -04:0441101.M 19 wdoerzia ett Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 131945 Type: Office of Consumer Affairs and Business Regulation Expiration: JO/13/2012 Endwiduat 10 Park Plaza - Suite 5170 Boston, MA 02116 STEVEN A. SILVERMAN STEVEN SILVERMAN ' / 268 FOMER RD. „,„ SOUTHAMPTON, MA 01073 UndtrSeC re ta ry Not a1 w thout signature 400 lttas. - Department of Public Sulet:i fiwtrd of Builtlint Rettuttuiion and StAndards Construction Suporwisor License License. Cs 77279 Restrictetita: 0 STEVEN A SILVERMAN 268 FOMER ' SOUTHAMPTON, MA 01073 Exoirottont 6121120 Tr#: 26868 ■,aulti-soot t SECTION 8 - CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : S Sliver iaYL_ 077279 — License Number 268 Forcer Road, outham trrn MA 01f173 6/21/12 Address Expiration Date 584 -7522 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Steven Silverman.._ __._ 131945 Company Name Registration Number 268 Fomer Road _ m ___� 10/13/12 �. 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 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 -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 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you 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 •ccrtgN 5- DESCRIPTION OF PROPOSED WORK (check all appIidahls) • New House LI: Addition Li RepIacepe1it Windows Alteration(s) Rooting fl Or Doors . Accessory Bldg. Demolitior New Signs Decks ; 3 Siding f Other E- 1c.4 Dr:/,;(:,'•//y, or /10 )41.6,o,ra \lc p",1/;:i Lo:yrint:/"1 Pb' AtCauhcc*5 Po!' 6. If New house and or addition to existing housing, complete the following: J't rani ty rartidy b %titnni/' f,/t tuctlpitl PI! I !.17.` ,%(..//01/„,/t.t :)1 f. Ve',Hod ijf I r Wocat,tuv r\u odch CorT, ia ts/E Eme-gy C:4abl.F.At:e form a".tacl cb?_„ 10:) 't v.et Yes v 100 rt. f ofi c I rr 'iediee M1 • CLe,:f forffi c Ie I3uIi cod 2r',F; • Sti.tiC K C CA:y water 5,1')E) y SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT - /5/,dd /$5 5/77 / 7774 , as 0..vrtet ct t subject va;Arty ,'Iu!nrirl7P Steven Silve .1 , Valley Home Improvement, Inc. nt my 17.' /// ..;; b.„,/:::f FIR ;',,e/r it aor)1K,fic--1 — / ti■e„d1 4 ,40 l i ffi .41/1 Siaacure ut Owier V7S . _ —SteXen Silyexnian Valley Home Impromement,Lno. , fAlitrifYI7E1 AE(70 dec ate ":ne stetrie71v, 11(f ir/foir of/ or/ tIii f oir pi.:.//cifto// Yu nfj Ett ivy cz lee CC a nc SI:77cd .• "te Steven Silve Er. /./r %■YrN! / 7z-7 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 ary proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: S I r__..._w______ Department use only F ;EC 'vE City of Northampton Status of P �rf i,.# 1 Building Department Curb Cut /6ribeway f' �r nit . MAY 2 2 2012 212 Main Street Sewer /Septic Availab�itity 7 . Room 100 W ` r /Well Availability A- rthampton MA 01060 1' Sets of ''aural Plans ,, DEPT. OF BUIw ;r.� ' > . v � � a NORTHAMP � '•0-" :,7 1240 Fax 413_587_1272 Plot /Site P i i,X. Other Specg -, ;- , . 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 ./Cc- J / z c'c -,/l� %1 '/" -.- Map Lot Unit �' /- 0/ j /j C L / ///, � `C / , �. 2 _ Zone Overlay District Elm St. District_ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _6' e c �iL (' /lie i� z /;/ZeCA. : t rf- ISS /'- S7 /77,--- /-/( `t, t/"/ c 7/1,/ 0 / C Ce 2_ Name (Pr' ) Current Mailing Address: >. Telephone . J Signature ,, ' C 3 (- - C� 2 9' :7 2.2 Authorized Agent: Steven Silverman Valle Home Im•rovem =,. s P.O. Box 60627, Florence, MA 01062 Name (Print) , ' I Current Mailing Address: iI 584 -7522 _____ Signature - Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building c0 (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) J) 611) Check Number 6 11 3 C- This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date