38D-025 (2) ��ttAMp2.
9 ' � 0 o f ('Lxtr of Nort1 &ntpt n a =*
$ � tie+ j j asaarlinsetts =� =
w _' DEPARTMENT OF BUILDING I.NSPECTIONS =_` i=
212 Main Street • Municipal Building '
Northampton, Mass. 01060 � us s"
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Air LS O Af EH / !��%LLT 1//14-. }i /i7L -e_. ../- ' ''/ � -4 C_
(licensetJpernuttee)
with a principal place of business/residence at:
3 `to /ldc. -S 1_b i)nii/ / /f/oZ/7/7707,7 ; i'l (phone #) 5* `f /ZZ
(street /city, /spt>/zip) dioh 0
do hereby certify, under the pains 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)
( ) 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) (Insuran.ce Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnecmary 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 %A ilo homeowners who employ persons to do maintenance, 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 compensation A t (GL152, s 1(5)), application by a homeowner fora license cc permit may evidence the
legal status of an employer under the Worker's Compensation Ad..
I understand that a copy of this statement may be forwarded to the Department of lothastrial Accidents' Office of Insurance for the
coverage verification sad that failure to secure coverage under section 25A of MQL 152 can lead to the imposition of criminal penalties
enaristing of a fine of up to 51,500.00 andlor ingnisoarnent of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.00 a day agaian tae.
Signed this 0 57 day of 1 e4 20/4 For departmental use only
Permit Number
i ' . /, t ` ,'" Map# Lot #
Signature of L3 Le f • ermittee _
SECTION 8 - CONSTRUCTION SERVICES
.2 Licensed Construction Supervisor: Not ,r pp icable ❑
Warne of License Holder :Steven Silverman 077279
L. cnsc Number
268 For Road,. S i _ _MA 01 073 - __ -- 6/21/12
Address i • f Xp : raoo'l G3_
1 •
584 -7522
Signal re Telephone
9. Registere&Mome Improvement Contractor: Not Applicable ❑
Steven Si lverman 131945
Company+_Name Registration Number
268 Fomer.n.,Road 1.0/1.31/2-
_ _ _ - - - --
Address - __._... Expiration Date
Southampton, MA 01073 Te'ephone 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 venial of the issuance of the building permit.
Signed Affidavit Attached Yes 0
11. - or>��te Owned enl E is I
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings ofene (1) or two(2) ramifies
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 750, Sixth Edition Section 108.3,5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which hc'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! ur farm
structures. A person who constructs more than one home in a two -weir period shall not he considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a f. acceptable to the Building Official, that lii'!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 wvork for which this permit is issued.
Also be advised that with reference to Chapter 152 ( Workers' Compensation) and Chapter 153 (Liability of Employers to
lLmplovees for injuries not resulting in Death) of the Massachusetts General Laws Annotated. von may be fable ;'or 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
pTioN- c)r- prioposcp
•
Nt 1 tc.:11:;t: Re..AaLcItte:11 dcw:, Rootivr,
As:CEE•SCI c Sgn 1 DE,Vr:s
STKk,t c-TU RA 1 - T6 PcZbA3T P1 ' F6b
610 TIV G Pt)STS
•
, —
if Nowitottse znt(I or addition to existing housina, con)piete tte.
tr:J; vt'A t < t at
‘t ! ;:t ; , t; ■< .0t Vt t t i tt
C 7i OWNER. ALITI:OFHZAT,ON - TO fl C07;Tt ETED WHEN
OWNERS ACEVT OR CONTRACTOR ARR I IES FOR 136,11. DING PERmir
nHt- Steven Silverman, Valley Home Improvement, Inc.
'7: d
d Steven_Silvennan,__Valley__Home_Improvement,„„„Inc.__
ttio„: t, ,r
Steven Silvery
if/
•
•
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
Bung Department
;
i
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 /Fi ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded .t the Registry of Deeds?
NO DON'T , NOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain ,- brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a p= mit been or need to be obtained from the Conservation Commission?
Needs to be o. ained Obtained , Date Issued:
C. Do any signs 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 1
RECEIVEQ 1 , of Northampton Status of Permit:
Bu (ding Department Curb Cut/Driveway Permit
I
'12 1 2 Main Street Sewer /Septic Availability
Room 100 Water /Well Availability
ort ampton, MA 01060 Two Sets of Structural Plans
phoneU3- ^:7.1240 Fax 413-587-1272 Plot /Site Plans..
Other Specify ,_____.__
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Pro ►ertyAddress: l This section to be completed by office
,,0 ` f HILL. ¶ &j 1 ii r,E Map Lot _Unit __. _
Zone _ ___ Overlay District
Elm St. District____ _ ,__ CB District i
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
t - 1 / of N E I L_ __ ___
Name (Print) Current Mailing Address:
1 ,t / .rvl. �' /° -c. - Telephone -i __
Signature
2.2 Authorized Agent: Steven Silverman
Valle H• • a Im• l•vem- !r ne. P.O. Box 60627, Florence,__ MA 01062
Name (Print) /1, i/ ) Current Mailing Address:
_ 1.11/ _ l✓ _ 58.4 - 7522___ — ___
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant t
1. Building 3 �( (a) Building Permit Fee
1
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 4 .. - 3 + 4 + 5) Check Number p 9(9 tf W itO 1
This Section For Official Use Only
Building Permit Number: __.� Date Issued: _ -__
Signature: __ ___ -_ __ . _____ _-
Building Commissioner /Inspector of Buildings Date _
File # BP- 2012 -0908
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 22 FORT HILL TER
MAP 38B PARCEL 025 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �� � !�
Fee Paid t0
Typeof Construction: REPAIR FRONT PORCH I N SA W1,€ FOOD 11
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
INF9 MATION 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
26 1 2
Signature of Building Official Date /
g g
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.
22 FORT HILL TER B P- 2012 -0908
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 025 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0908
Project # JS- 2012- 001594
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 4138.20 Owner: O'NEILL MARY E
Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 22 FORT HILL TER
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON :4/30/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR FRONT PORCH (SAME FOOTPRINT)
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 4/30/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner