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—c. ^y�' DEPARTMENT OF Ih
BUILD TG INSPECTIONS __ _ i
212 Main Street 'Municipal Building ' ,,
ti two s�sy
,
Northampton, Mass. 01060
WORKER'S COMPENSATION NNSURA.NCE AFFIDAVIT
(licenseelpermittee)
with a principal place of business/residence at:
3 -re.) iej /// MO7fii " ,,,/ /; in!" (phone #) `(6' - 7 7Z.._
(dr=t/citr/r t :rip) 4 1/6 45 0
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:
nZ 4 5 "S' �/ S. ('CJ . GI' C g6 i 5 / 2 / // /a
(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 shit if necessary to include information pertaining to all contractors)
( ) 1 am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE: please be aware that while homeowners who employ persona to do mehTt. an - , comstnuctioa or repair work on a dwelling of
not more than three units in which the homeowner resides or oa the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act (GL152,s3 1(5)), application by a homeowner for a license cc permit may evidence the
legal stains of an employer wader the Worker's Compensation Act.
I understand that a copy of this stalarsat may be forwarded to the Depautment of Industrial Accidents' Offioo of Insurance for the
coverage verification and that failure to segue coverage older section 25A of MOL 152 can lead to the imposition of criminal penalties
coesisting of a fine of up to S1,5O0.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fitter of 5109.00 a day against me. jj
Signed this /,J r' day of / ` 9 . )Cl For departmental use only
( r Permit Number
7M / /1 c4 ',t�i�e1 / °� _ Man# Lot ii
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Board of i
Buil( 1 ,
V,A Construttion Supervisor License
Massacilu.setts:nDocRpea,1tu ni
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License: CS 77279 I
Restricted to:
STEVEN:k
, .
268 F.OMEK.RD ..
,,,,i, s;:p,..:.;.,:.e1-; 1 •
SOUTHAMPTON:MA 01073
010 \ "
. . . Expiration: 6/21/2
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BOrT‘Jeot141141ineiltagligi 94 idZegraff4fP •
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR
.--3... ---== before the expiration date. If found return to:
Registration: 131945 Board of Building Regulations and Standards
Tr# 275412 One Ashburton Mace Rm 1301
..._ .
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STEVEN A, SILVERMAN1 :
•-, --,,,,,.: :,,,.:-:., , .
STEVEN SILVERMAWt - ', - i:.-tt 2 i'. ,
''-',':54';1„:',F.•a",s; ..,'
268 FOMER RD. ..:,:.., .--,::,--;,-:-- :.,--' ' C)-...g.„....(Q.•-e,---._ /(15 / 1 1/11 1'4 1 / 4 %/ -
SOUTHAMPTON, MA 073-:L' ,..."'i , k ../ i ( j , i,/,7 ,,,,,
—
Administrator 1\lot valid without signature
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SECTION 8 - CONSTRUCTION SERVICES 1
.1 Licensed Construction Supervisor: Not ,,,, p icable Cli
Maine nc of License Holler . Steven Silverman _. 077279
License Number
268 Foxner R ad ou.thampton,.__r+rA t?y t1 3 ___ __ I 6 - -- - - -__
I Address Expiration Date i
A t ,- ' 584 -7522
Slgnarur., • Telephone
J,. Registered,,Home Improvement Contractor: Not Applicable ❑
Steyen.Silverman - - - - 131945
Company_ Name Registration Number
268 Fomer Road 10/13//0
Address Expiration Date
Southampton, MA 01073 Telephone 584 -7522 1
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6) r
6 Workers Cornpensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit I
will result in the denial of the issuance of the building permit.
■ >igned Affidavit Attached Yes �i No 0 ���
.� I
11. - Home Owner Eierno on
The cu exemption for "homeowwmet " 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 vyho does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5A.
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 -near 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 buildinti permit.
As acting Construction Supervisor your presence on the job site will be required from time to tine. 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 anav be liable for person(s)
your 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
•
DEr.SCRIPTI:IN P.qoPosto
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If New house and or addition to existing housing, contplete the following.
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SECTION 7a - OWNER AUTIIORIZATiON - TO BE COMPLETED
OWNERS GENT OP CONTRACTOR APPLIES FOR BUILDING PERMIT
7/24Re__ i3k_ai/4 011-11, L11_,,ed/eiej ,
Steven Silverman, Valley Home Improvement, Inc. , 3
y, 3 3‘ 3, ”1 3,3 Itt
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Inc.
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Steven Silverman
/60,
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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
f .
Fill:
(volume & Location)
fi n
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 cont ' 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 any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
~ A
l
� Department use only I
City of Northampton Status of Permit:
-.,.• Buildi' Department Curb Cut /Driveway Permit _- -
(' ' ,u212 )Main Street Sewer /Septic Availability__ _.-,.
'; ?
`
OM 100 Water /Well Availability
' Nora ampton, MA 01060 Two Sets of Structural Plans
phone 413- 5874240 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. Property Address:
This section to be completed by office
` c /(, 5/ Map _ Lot _Unit
r ��l 7711 4(51lUb Zone ,_ Overlay District
Elm St. District__ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /39 % -
, 1/fr-ie ez 9 0/049 L Ged./1i. / 1/P77/ - /7 -- M � /17/t G7/ 0
Nam Print) I Current Mailing Address:
Signature �`7' 3 3. 3 9 V 3
2.2 Authorized Agent: Steven Silverman
Valley Home Im.rove•,_t Inc. P.O. Box 60627, Florence,_ MA 01062
Name (Print) Current Mailing Address:
l ,i / . _ 584 - 7522 .__._ --
Signature / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1 . Building (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) i !1` Check Number a (6 036
This Section For Official Use Only
Building Permit Number: _ Date Issued: _ __ - _ ___..._
Signature: _ _ .- _.__-_ -
Buliding Commissioner /Inspector of Buildings _ Date
I* i BP- 2010 -0495
G1S #: COMMONWEALTH OF MASSACHUSETTS
r �I = CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit tt BP- 2010 -0495
Project # JS- 2010 - 000683
Lst. C ost: $9.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 9888.12 Owner: BRUMBERG MARK D & DONNA B LILBORN
zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 139 FEDERAL ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11/4/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE 14 SQ & REPAIR ROTTEN
FACIA
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 11/4/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo