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,_': — DEPARTMENT OF BUILDING INSPECTIONS ____�_i=
212 Main Street ' Municipal Building ' ;
• Northampton, Mass. 01060 ,~ ow s"
'
WORKER'S COMPENSAT[ON INSURANCE AFFIDAVIT
1, /V2 L50 Af sin /GP%Lz_/% vAez- fi e_. ,1�7/ x-e4r, C
(licenseripermittee)
with a principal place of business/residence at:
3'o / el //Les i .6 8 i),Llii'z / ,f/0 2f �/Ji ; g'I,f (phone #) 58 g- � 5 Z2 .
(s et/City,i5n-t zip) 4 / O
do hereby certify, under the pains and penalties of perjury, that:
( j 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)
( ) 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 pavans to do maintenance, _ construction or repair work en a dwelling of
not more than throe units in which the homeowner miles or on the grounds appurtenant thereto are not generally oonsidered to be
employers under the worker's conpeasation Act (GL152,ss 1(5)), application by a homeowner fora liege cc permit may evidence the
legal status of an employer under the Workees Compemation Act.
I understand that a copy of this statement may be forwarded to the Department of Industrial Amides& Office of Insurance for the
coverage verification sad that failure to segue coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fax of up to 51,500.00 and(oc imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.00 a day against me.
/
Signed this . / 57 day of 201&. For agar us: only
Permit Number
11 • ,/AL I . ,'7-12-4. Map# Lot #
Signature of LT .. _ • ermittee
„,./ e fir,)ambl-if i_../1/1
t - •
01The 01 onsumer Affairs and Jusiness Regulation
1 0 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Rectistration: 131945
Type Individual
Expiration 10/1312012 Tr# 204690
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
I pdate Address and return card. Mark reason for -change.
= Address ' Renewal Employment Lost Card
DPSom 0 5
; ;;(4 0- e4ozwie,frurwala liawzivias;A
Office of Consumer Affairs flasiliess Regulation License or registration valid use only
HOME IIMPROVEMENT CONTRACTOR before the expiration date. If found return to
*>" Registration: 131945 Type: Office of Consumer Affairs and Business Regulation
Expiration: 10/13/2012 Individual 10 Park Plaza- Suite 5170
Boston, MA 02116
STEVEN A SILVERMAN
STEVEN SILVERMAN
268 FOMER
SOUTHAMPTON, MA 01073 Undersecretary " t < i thout signature
•
li i
i
tit
p i t u rv r t l a l e t s tl i o i l f P
i rd'
License Cs 77279
Resincted to: 00 '
STEVEN A SILVERMAN
268 FOMER RO *N•
• SOUTHAMPTON, MA 01073
E 8121/2012
Tr#: 26850
t .131mi-soot t
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steve. Silvextan_ 077279
License Number
268 Fom- Ro- . . _ „. .n, MA 01 (173 6/21/12
Address Expiration Date
584 -7522
Sign. re Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman -- 131945
Company Name Registration Number
268 Forcer Road 101131/2 _.
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 )ifl 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, 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
• f:c TION S. DESCRIPTION OF PROPOSED WORK Ccheck MI rIppljotts)
,Now House LI ,. Addition LI Replacement Windows , Aiteration(s) 1 Roofing n
Or Doors ::: i 1
' Accessory Bldg. D DemolitionD New Signs : I Decks : 1 Siding 1 1 Other
. ,
731 Drnc on r,; Pr( r.: ■N( ' K R br 00 C._ C) r Ft/ 1.,4_,
,,, ."" Y 1c' ;n,:i :1r-1: __ __Y.'.. ..___ `4C) A1 up. tl....e.' !"*(1 `I`Evi `,V, Jif AF z 4
:r.t.`.. % Toth...? v`i-t37ltlr: ;f., ...iii,-Ilt j t..;k1:,
PI3 .` POI: Stt,
6a. if New house and or addition to existing housing, complete the following:
1.P.E.- :;,1: icav . C'E ,• 3111 y Twc) 7 amdy 0',.'f:r
: b r% k.Frrrof rr* to..;. F. ,i each !al-i:y :int "
: l', " 'we: :t
J FTI 34:,./.14 r,:. kg, i ,ip:tt :!. u7 : t.r.
, :,i7 . 1ftz,./
r. Ve:i of !ic,:i'orig'' r I° t-r. ;.,(....;-, , ,ii Wccth;tov Nur-1;e' u eoch
, e F'PrL CC - Serv;ItiCr , 00r iii „_______ _ N'zsr_Ck ErICIV C11 fDril ij:ti3C1 cd? _
<,,I cr',.' f,If!...:lici
. '.. 4.:C I W, WU 1{X} 1. ''Pr V. , ft.t i'.3■IGS? `: ..71 s \13: li, c,:ossts:Ict,:ni w *:;-,tr :00 yi , , Yet., li:r 1
nt nw,ernont :";',!' Celi:tr I ,:')Or below 'Innl'ie0 af.lCie [
1 .. €
NI (I cc7 fOr' IC ;he t3w1:7:inp,, xld 2 Y;:. No
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— 1
SECTION 7a . OWNER AUTHORIZATION . TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r _ .........”._ _
as Cp, d t'e subjce:t p
, .
lic ,:iii°,!',n,97e steven Silverman._ , Valley Home, Improvement, ..Inc , _ :,..-, ..:'.t on
ril, Lf:. u 11 - 1;1°.ttett , •e, ,, ,4 .'e 11,11 i'l.:tlicowec. tr, In b.,„1!:1, ni: ."); K11,11.;„
• ste_v_en S_i.lverman,___Valley Home Impr_oYemeat,,_1 c. ‘, w, - ,..;-,crif,t /Autrm Art
hs' deciiic ' - '4 ' , i-r. ": '.L Irlf (171 the 1 °TcRo ir ii aorlicdticT :Ire ';'te Ortd ilk:L ;:ttt-,,„ ki ',lit
I..r ci.1 cc znd hen.
Elnd
._„Seven Silverman __
t.'r%f I N;r7
[
S■41 : 47.1 '.:, eN II?' ■ :: r, /V
rqt tf! .z7/-77:,
C—.1 I / 2........■—■
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 my proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Y Department use only
ity of Northampton Status of P
j 1 2012 uilding Department Curb Cut /Driveway P
212 Main Street Sewer /Sept c Aval(a '
s ,
Roo 100 W ty
DE- F _ 1060 ti f /Well Availabili
DEPT GFBU� >�
NOBTNAMP' i AQ C60 orthampton, MA 01060 1W 'Sets of ' j ctural Plans
phone 413 - 587.1240 Fax 413- 587 -1272 PI /Site
Other Sped (
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
C j Cj/L Map Lot Unit
% L c)". jj ( -� , `)/7 ei `Li (, 2_ Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
--
2.1 Owner of Record: /_ (). 2 COX
if/ , I . 6%/4 .` T 4 3��C= /1571//t111,/7) i 174 01e; Z 7
Name (Pri t) r Current Mailing Address:
i 7 Telephone —!
Signature �
2.2 Authorized Agent: Steven Silverman
Valley Home Improveme t, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) % / Current Mailing Address: / /it
584 -7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ('p) (a) Building Permit Fee
2. Electrical 30D (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 9 uuD Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 4r JO) Check Number z9 a q 55`
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1063
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 115 OLD WILSON RD
MAP 44 PARCEL 016 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Zi
oV<O V
Fee Paid �
Typeof Construction: REMODEL FULL BATH
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
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.
115 OLD WILSON RD BP- 2012 -1063
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44 - 016 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 -1063
Project # JS- 2012- 001837
Est. Cost: $9200.00
Fee: $55.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 30796.92 Owner: STAHLBERG ERIC & GAIL
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 115 OLD WILSON RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON :6/1/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMODEL FULL BATH
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 6/1/2012 0:00:00 $55.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner