24C-033 (2) 0s cotAMP yO
9 w Oil t Qtri o f NariI &ntptert 1 *
9 .i j « lassachnsetts =_� _
1n 5 D EPARTMENT OP BUILDING INSPECTIONS t
212 Main Street Municipal Building .„
Northampton, Mass. 01060 � �
" y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I iitsoAf sH // f7-L77 - f l/M --i— - y f/ ' tag ./=r 7 f ��; c
(licenseeipermittee)
with a principal place of business/residence at:
3 , fo ,e /L $ / es i) ✓`Z,a�2t7/17A -4 1'/,1 (phone #) x'61'- 75 Z2
(strmti cit /5;at> /zip) D /od U
do hereby certify, 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 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 coo actors)
( ) 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 employ persons to do maketeaance, construction or repair walk on a dwelling of
not more than three units in whichtbe homeowner midi or on the grounds appurtenant thereto are not generally ooasidered to be
employers under the worker's compensation Act (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 Act
I understand that a copy of this statement may be forwarded to the Department of Induatri i Accidents' Office of Insurance for tha
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consistin=g of a free of up to S1 ,500.00 andfor imprisonment of up to one year and civil penalties in the foam of a Stop Work Order and a
find of S100.00 a day against me.
Signed this / 57 day of / 20/4 For departmental use only
Permit Number
i j ' .1A1 . / ' ,0 Map# Lot #
Signature ofL'..e - •ermittee _
, y
O1lce of Consumer Affairs and usiness Regulation
yv,Vit ., 10 Park Plaza. - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registrahoon: 131945
Type. Individual
Expiration: 10/13/2012 Tr# 204590
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
Update Address and return card. Mark reason for t hinge.
Address .__ , I enesal Employment 'ant Card
t ?.t v 50M-S4V:4-G1t;INfi
.: t) tTir.r ofC onsumer Affairs & B inrss Regulation' License or registration V alid for individul use only
" before the expiration -late. If found return to:
�� aa4 eg t aeo 13 1945 5 CONTRACTOR AGfiQR Type: Office of Consumer Affairs and Business Regal; tiara
r Y 10 Park Pla:r i - Suite 5170
Exp 10 11312012 individual
Benton, M :t 021 ; 6
STEVEN A SILVERMAN •
/k
STEVEN R 4/
� EtS SIi.L�E �
266 FOMER RD, .-ii. _, /�
SOUTHAMPTON, M A 01073 Undersecretary Not valid svithuut signat e
atio
1l ssitchusetts - Department of Pubin: "
ttni of Doilt110 Itetuintiott* anti °stn ,artfs
it .
ConstruetiOn Supervisor LiceritS
Linen e. CS 77279
Restricted .to: 1
� A , .
STEVEN
268 FOMER r 14? ,
SOUTHAMPTON, , MA 010 ,.,
; , - „ , - " Exfrat. -tort: 1/2012
t � tniiiit iiri r
Tile 2668
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman_ 077279
License Number
268 Po. R•a. ; , - , , . . , , MA 01 A71 6/21/12
Address Expiration Date
/r
584 -7522
Signature Telephone
9. Registered Home Improvement contractor: _ Nct Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer Road ___ _ 10/13//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 lal 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 fonn 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
, t
. 7,CTION 5. DESCRIPTION OF PROPOSED WORK (check all applicable)
i
Newt House L: [ Addition Li Replacement Windows ; Aiteration(s) Cu Roofing 0
Or Doors
Accessory Bldg. .: Demolition New Signs : 1 Decks 7 1 Siding.* Other . )
_i_
Dr„-x-s:,-e, on :2,' Pr I.X;',u(': Nb..;., QpL 1•01
on .
1tte:'1:",i'l V-e. No 14:1 up, rw fa-.firrtry-
%trri,,sk.t. it-'1:.Pit1 tic-F, ..II.1UylIJ etv...runt.'nt Yt:',.•, Nt;
Pb :, , °q!.. - .11:hczi For S
6a. if New house and or addition to existing housing, complete the following:
e tIF.t DI :u c'' . C.:` 7 2411 k' T'A'0 n ____
i
b I\ 11 .ir.,tr:
a:lac:Mee?
.1 r SuJeJt..7 I,. k.';' new :,„ ': ;)1,ert
„.. 7 i•-•! .5t ‘,."
t. 'idt 0' "it.:01'n,”' 1 i• tr, ;;:,:tt., .:r 'Aicc.,....th,tuv.:..s... Nu u` tocti
e F. Cc-m, Oor ia zc l Enc-gy Cpm,DIrarize fDrm attz.c6 cc?
1 f,t m-:r,:lt,..nttoi
• ._.. ec; ,v,11H , I (x,', .1 ;,o1v,t 1 les \1::; 1.1. r.:Aistr,..,cr,mw.*.tT‘ 100 yi '1iaLA
uf nw.tuntlill ...',!. ce.1%•tr 1 Dor Uelno Tr'ef',.11(±C.1 i'u'IC,fr
:'..)u ic't cc form IC *.'',C! BuR:olp :tnd ?nong t4:...1.111C:'!".?
• Sel.'.tle - al'ilc 0 `..y ";:.; Pr vati-. v.ei ;31',.}, v.ater Si v
i ,---- ----
1 SECTION 7a - OWNER AUTHORIZATION . TO BE COMPLETED WHEN
1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
OW/ /Lj /< _ „ , as 3P4oCr d t Subjed Vty
!R.: (•h au:nret7it. _S _eyen , Silverman, Valley, Home Improvement, Inc . :A ..1t1
ri br.: r! ,:ill -- ti°,1, rS `e':.qt.'t tu w• ;:,ts11tG tY, thISL ni: )6 a ,71O1;11C,SItail
--11--- 1.. '4' A II ALA4 1\ L IL
sikr a:1113531111111 :sou,
. .ateven Lilvetxman, valley Home Imprsixement._Inc..._. Ac. '-' AE:
tvt".: dcci.'re:77.1: •. 1.,taterric :.,.11(.5 inf:drtt:Jr1 Cr: ttle frOleROir P. a;_112 , ..;,rt: ;•lic tor,' iief,3r:Ite, to lie 1..); e' ivy
kr c ge ,-..- nd belicF.
S t7, - ,cd ..;-c;,..- - .1 - 7: DEN--,..-, z--j
Steven Silv 7.1- # _ / ____________
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_ ..
A
.? Co' : 4,.
/ ,
/A/2--
.
f
— Department use only •
Iir I ®. -. ,l,f , jity Northampton Status of Pe it
Her g Department Curb Cutli w �way i
[u�2 f 21 Main Street Sewer /Septic A vall a i ity ;
oom 100 r /Well Availability
c e r ha pton, MA 01060 Tw• Sets o€ , i Plans
- -- --- 7 :phs���k� =t87 1240 Fax 413 - 587 -1272 Piot /Site PI ! . ; : r
Other Speci ` *i'
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
60 A L_ /I c, 2 Map Lot Unit
/ ' "`i ' e.-711-4/77 11/ A / / .i to 6 , Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: G' �'` t. /%YC_
L Sf v r l rift t_/ /0 C �' 2 A-1)7/71#7/7/// /, , yI1, C G 6 �
N. e (Print) Current Mailing Address:
-� 4. , , , t C CAI Telephone 9 676 G
Situ �e
2. • Authorized gent: Steven Silverman
Valle Home I, •rov -_,, - f_ P.O. Box 60627, Florence, MA 01062
Name (Prin � / Current Mailing Address:
/'1 / 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building T ,t 5-(g) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing f . Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) i t 5 Check Number 67 qq 5"
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0909
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 60 NORTH ELM ST
MAP 24C PARCEL 033 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ?at
Fee Paid
Typeof Construction: REPLACE SOFFIT & SIDING IN VARIOUS AREAS
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
INFOXVIATION 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
C%- 1 Z6 it Z
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.
60 NORTH ELM ST BP- 2012 -0909
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 033 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0909
Project # JS- 2012- 001595
Est. Cost: $4500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 17816.04 Owner: GAUBINGER JOSEPH R & ANN C
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 60 NORTH ELM ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/30/2012 0:00:00
T O P E R F O R M T H E F O L L O W I N G W O R K : REPLACE SOFFIT & SIDING I N VARIOUS AREAS
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