16C-019 (2) 0 4,(ttM1F2 O entsu
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B �i� ,�� ` � AassaClIItEttta :Z.v y
c . JY �'_ -.. DEPARTMENT OP BUILDING INSPECTIONS _ Cf
212 Main Street • Municipal Building
O ,y y
V, i
Northampton, Mass. 01060 S
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, /f/i L5oAr Sid /pi%LLi I/ -.5" L- , '/ 72 .a/2 ifteri 7, `tC
(itcenseelpermittee)
with a principal place of business/residence at:
3 f i t . ) 1 v 5 j i5/1_lii`� / ,�/D,�Z . �7%i ; old (phone #) 58 `7 7
(street /city!stai izip) and O
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 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 persons to do maintenance, cvmrrudioa or repairworic on a dwelling of
not more than three units in which the homeowner resides or ca the grounds appurtenant thereto are not generally coosidered to be
employers under the wocka's cortzpztiaa Act (GL152,ss I (5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workers Compensation Act_
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' 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 $1, 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Omer and a
flat of S100.00 a day against me.
Signed this ®$ d a y of j j 20/2. For dep al use Daly
Permit Number
L / ' .,/.1 a m • 4.° Map# Lot #
Signature of LS -. • ermittee
•
,./he.. - to amwtoliet,Aealtit ,/.11:421,ttatif.Neird
Office of Consumer Affairs and usiness ReLi,ulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 131945
Type: Individual
Expiration: 10/13/2012 Tr# 204690
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
Update Address and return card. Mark reason for change.
Address ' Renewal - Employment Lost Card
DPst.',A: 0 sorkt-o4s4-sicmyis
,c1744 mrsio.n.nwezia I
Office of Consumer Affairs & Biisiness Reguiation 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
12 : Expiration: 10/1312012 Individual Id Park Plaza - Suitt 5170
V
77,4
Boston, MA 02116
STEVEN A. SILVERMAN
STEVEN SILVERMAN -
268 FOMER RD.
SOUTHAMPTON, MA 01073
Undersecretary 'et valid without I e
skrlatur
° *
ago
Massuclutwtts - Departnnerit tf Phtk Safet:t
- 1391 of Buildino Rev:111;0.4;m anti Staudards
„
r'oristruction Supervisor Livertse
ocense- CS 77279
Resincten to: PO
STEVEN A SILVERMAN
268 FWER
SOUTHAMPTON, MA 01073
Exotrartorc 6/21/20
t TOP. 26468
trwari,-.i=orr r
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : S teven Silverman 077279
License Number
268 Fome t. - • , -4. .n, MA Q1A71 6/21/12
Address / Expiration Date
Jill i //v 584 -7522
Signat • Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman _ 131945
Company Name Registration Number
268 Fomer R 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 0
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. CMIR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which heishe 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 persons)
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
, I
- 7,c_TiON 5. DESCRIPTION OF PROPOSED WORK (check 411 ziparerAttr)
New Hu t.e L Addition LI Replacement Windows ; kteration(s) E: i Roofing X
Or Doors :1 1 _
Accessory Bldg. D Demolition New Signs J Decks : J Siding f i Other . I
,
..................„ .... .,..,.._. ,....._. __ ..„...... ____,, .....„„„„...„_,..... .... ______ ,
. 7- v . ic!' Derrc`rrY: wr tri i'r;:ro'r,rt(i Aro k kt f 2 - p/ire. goof oin. limn) lviArre,,
CI":l ne; nee.,' :'*.reirnor'r
:Ar.dr.rte:; " f..i.LriotJ.‘:.: ..lif I;o7.,t...itioir
' P13 A.ttas Put
6a. It New house and or addition to existing housing, complete the following:
,-, 1 k•.t:- of oh ICsr-/ . C'E :7 a Ift ly Tri.,,) 7 armiy
. • — ., — -- :
t111 Cr' Ic:::'Y'S , ri Eiii.:t1 ', ilf". t Nurnni fit :.
:: C. .rfrtachec?
Li r Srrorlr e krrrCiErr. rr itrrrA ,,,(,A r. It ;/t- ',At
7 1r-r- .r rrr'orr•trsi
!. "/ e:f Of rierrilir'' 1 irtirr . rr,trrr... "...:r WC(rthrtoverr, Nir-tt,rr r/ troth
et 7y C:17.: 0,97'D la N EFIC.Ty CM,DraliZe f :4 91 DIZCI,C.C:7'
.:'.I 0.C"'fftf !..11c.n
1 0:: 1 `,1 7.Kritar:S? Yes 'C.:. ii, CrAtSrlt.ict,:Ar vt 100 yr , °IkrrorIplit.:1 Ye,
rt. ot r1; ce11,rtr 1 :)or t'Jelc.,..
. i
,: N:ri ;:m.) Idarrii rrcr form to *,tre Burk •ir'rrri ?rr;rrry-rp,
r.
Sc Tr i :Y Se'N'rt l'r.v,y,e , ,, , ,e:i C;t:y viatet S;.v.v y ___
.,....—„.—
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• (
iviktu& ta-c/T , , as 3..vrier et subject vDpctty
of.--:•1:..y ;,u!-:nr'r _Steyen Silverman, Valley Home Improvement, Inc .
r : -. L !1= v d I --,;,,h, tu v.,74., ;ltiti tiy Ihrf. t.)„.1;.: irirr,. il.rfrrrrIt acipilc,'Illo I
_
Z ,
16.--den& b/ () 2( Z---
.
Sr a:Jre 01
St.salt_en__Sillexmark, Valley Home Imprsotement,_Inc_a_ „v- ,:;., ApF,r,t
JPC ',7%T. ". S',;...ttcule NW Ir!forr e the for eiripir e, itori.c.4110!, :Irt •kst-, or.:.i ilec:re,l,tt., W 'JR:: bf....:,!, b' rry
. nc bclicf.
St.:nrld ..:7:Crv' tr orL-1 zrord tK. Li
St even Silverman__ , / — ----
T3 ,'."
/ ,. /1/
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 Rer stry 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 b -en or need to be obtained from the Conservation Commission?
Needs to be obtaine Obtained , Date Issued:
C. Do any signs exist • the property? YES NO
IF YES, describ • size, type and location:
D. Are ther- arty proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
/ ' ..
1 ��!` ,, Department use only
_ , � City of Northampton S tatus of Pe ►t �z;,
�� i, , uilding Department Curb CuttOriVeway l?el=rr►I � -
nj , /o�° 212 Main Street Se wer /Sepfic i y � .
,�� 0�° Room 100 W1a rIWeII Availability `
V � ,r, �`� Northampton, MA 01060 r •�Setsof, ',:'ctUral Plans
4F,n�g� one 413 587.1240 Fax 413 - 587.1272 Plo t / Site PI S
,„v r ° � Other Sped ,
, ,,, , < r ,,,,4,,,;,,,,,,/: '
\ 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
41 ` P 1ki (: 3T.
l Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: .
M ft'f le- E C lc. S' re:- U 0
Name (Print) \ ` Current Mailing Address:
\ N... \ Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Valle •me Im•r'. emen_, A. P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address:
1I I /if/
584-7522 -
-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3 l02b (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) 3 (0-2-o Check Number (��19// �
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date 1
410 SPRING ST BP- 2012 -1117
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C - 019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -1117
Project # JS- 2012- 001909
Est. Cost: $3620.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 131115.60 Owner: ECKSTEIN MARK & MARIA BRAZILL
Zoning: URA(100)/WSP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 410 SPRING ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON: 6/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF
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 6/13/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner