37-022 (2) i�o °i txt of NDrflr&ntpttnt _*
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`lw� DEPARTMENT OP BUILDING INSPECTIONS
MO - - _—
• . 212 Main Street • Municipal Building . ' o., —�•,.
4.
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Ali LS o kr s// / / /%4_4. % , (//Iz-I-L y /7 G,'�7 -c f X-e4 %, J L
(licensee)permittee)
with a principal place of business/residence at: .
3 ,10 /2> l/f .5 i.b a i),Liv O,�if ./7r0i ; /4, (phoneti) 58 `/- 7,
(street/city!s tJzip) Dio
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, construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's coropecastien Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal statue of an employer under the Workees Compensation Ad..
I understand than a copy of this statement may be forwarded to the Department of Industrial Aoddeate Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to SI,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fate of 5100.00 a day against me.
Signed this - / Si day of / 2 For departmental use only
�'J /j Permit Number
' / �t� f� l/ /' 1 Map# Lot #
Signature of L —' - • ermittee
6 - lo. It/ 4c/ zet6
-ntynoliet,,,tea„ iatkiae)
2.1 -14 •
Office of Consumer Affairs and usiness Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 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 change.
= Address Renewal - Employment Lost Card
OPL-CA1 SOWN/Da-MO*18
,c7k-
N
Office of Consumer Affairs & 8 sin ess Regulation License or registration valid for intliv idol use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 131945 Type; Office of Consumer Affairs and Business Regulation
N o 4 /,4;
ov Expiration: 10113/2012 Individual 10 Park Plaza - Suite 6170
rs1 Roston, MA 02116
ST EN A. SILVERMAN
STEVEN SILVERMAN /
268 FOMER RD. -
SOUTHAMPTON, MA 01073 // •
1;nderser rotary d withou signa $ re
„ow
asiti: bowl ts De pa rtment of Public Safet:i
Soa n ar s :Lu c iilg R
t t io iti nsu e po tsiia n
rvls ti o u r s i a lc n e t1: „ s t e audarits
License: CS 77279
Restricted...to: OD „.•
STEVEN A SILVERM N I
268 FOMER RD
SOUTHAMPTON, MA 01073
Elonation: 8,71/201#
Tot: 2685B
t Nowtoil."%logit
No
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S teveri Silyermran__ 077279
License Number
268 Fomer R a Southampton.,, MA 01073 6 /21/
Address Expiration Date
584 -7522
Signaturt 1 Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman T __ 131945 _
Company Name Registration Number
268 Fomer Road 101.
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 110 No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (I) 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 -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 he
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 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
"r:CTION S. DESCRIPTION OF PROPOSED WORK (check all apatiobik)
. .
Ne.lw House L".1 , Addition Li Replacement Windows ,' kteration(s) 0 Rooting 0
Or Door (
Accessory Bldg. 0 ; Demolition:I New Signs : ) Decks i,e) Siding f ) Other
..........._............. .._
, a'ir Chn.c.'i:S: On r.;! PIC'potic AT/ k 11-4(Act, e l Ect sF 0 E . lv 5 c t i
, r u oi l i
r!r. t,i n -V e btln. _ ,.. _V.7e, ._ 7 No A f':L lip, new riftd
4 ,tti_i,toc; ' F .„ `,..41
P13 Afla:tio BoP S
6a. if New house and or addition to existing housing, complete the following:
,
7& Dt ".."Ai IC: riE : C '',E 7 arri ty Two 7 .amtl.,.. Or:
, 1
t., Is;;:ri i";" f C;S 1 eadn 7,Sr^t;y ur,,I: "\lurin o' iizithreo/rF
r..-1:fn orv.e ;z1;;;„:Lhec?
j r SC,Ahire tiX GI new .,i'l.troCk'irl DI,nel6R)•1.,:,
t
t. I-e:h..DJ Ls 'cot lrie I i ii ut.- t, ..;n WCCKit;ttivtr, Nurt..,-, uf ich
. 2 F ;:ry Ce Cor iarc-7. W2schcck, Enc'gy C'..:4 form at tact co?
: CCnt __
CC VAI .tiC 1 vhthri I C.:} 't ;It wel:a.,11ksls? Yes Nc.) I c: g,v,'.a tr 100 yt. *lo Yt.S. _No
ot na!',„et o! cel;;Ilr I or ne 'Intf.11&O alaae
k ',. ;NI Idwg oo: to Ihe Budding ; ? ret.Aatic'
r L Svi:tic 7 a• C.7.y Se Pr vate we,11 __ f...;Ity water St*t.1 y
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
:
,, _I■ ,f-kid ew4(.50 „ • as Owner el t.."e z,ubject property
tif—eby i'tti!nn: 17e Steven Silverman, Valley Home Improvement, . Inc. , to :t on
rrs; ty2-y,..tif r• 11 f to wo0c '1:1,ric-rieo tri tro, b..,t`critg 1.)enrit a
,„,..3 i
w. --• 16. •
, ..._ _ _ _. _ • ._.._,
Sii.:ca:Jre 07 061er Lsot —
• _Steven .ilyerman, Valley lioxne Improvement, Inc . it (.).. Agftnt
.
dcciure thnt :nt° stateinc7xs ... infolmi e71 the, foregoir g appl „-:rt.: : dud ;:so.xk.a:;:ttl, to 'li t. bet,t, n! my
1..r c.41. End belicf.
C 11 DiairL'i Er'd c'Vii.f iln tt'
Steven Silve ,1 ;4
X1.-----41 EglItt
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F -3 t Natr”
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ifti
4,
_____ ,,.....,.._ ...........__
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 ev: been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued: /
IF YES: Was the permit recorded at th Registry of Deeds?
NO DON'T KNO 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 perm'' been or need to be obtained from the Conservation Commission?
Needs to be obta' ed Obtained , Date Issued:
C. Do any signs exi:t on the property? YES NO
IF YES, describe size, type and location:
D. Are tl2ere any proposed changes to or additions of signs intended for the property ?YES _
No /
IF YES, describe size, type and location:
t
1 1, � � , _ ' , Department use only
�'" y m Status of o
a��2 Cit
\ ,�� - s uilding oif Northa Departmen pton o Curb Cut /I PMit: eway P rrnit .,-
� � P X0,5 ` 212 Main Street Sewer /Septic' i y
\ ,,
�_ �
,AP " Room 100 I Well Availab
s :
' 'C' " N MA 01060 1' " • . Sets o
o / �• f� irirctural Plans -
„✓ phone 413 - 587.1240 Fax 413 - 587 -1272 Plot /Site P l
Other Spe6I . 4 y
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address: , /�,� 1 /�
2't- / /CGGI 11741 .t L���J / Map Lot Unit
/� v /C ( /nit e Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 2 L- 41 e `t el ni7 ,t' L #" 'e--- // /fTh"
91,'/. C i U 0 /- -,' C/'t � i t�r`Z, d/ 3 ( Z
Name (P) Current Mailing Address:
I') �
.
/ . ' Telephone ,.f� 2 2 ' t_�
Signature 1" 3 . , � 2 7 .3
2.2 Authorized Agent: Steven Silverman
Valle Hoie Im•rovemeiL f P.O. Box 60627, Florence, MA 01062
Name (Print) _ _________ ___ / Current Mailing Address:
` 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
, trio
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) 2 OW Check Number ,g019t 4;575
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0232
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 22 MT LAUREL PATH - 600 FLORENCE RD
MAP 37 PARCEL 022 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid dv 9e,
Tvpeof Construction: REPLACE ENTRY DOOR & 24 SF OF DECKING
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
INF RMATION PRESENTED:
j.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
Signature of Building Official Date
�l
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 MT LAUREL PATH - 600 FLORENCE RD BP- 2013 -0232
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 022 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Peimit # BP- 2013 -0232
Project # JS- 2013- 000382
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): Owner: CARUSO DAVID A & SARA HUNT
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 22 MT LAUREL PATH - 600 FLORENCE RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:8/31/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE ENTRY DOOR & 24 SF OF DECKING
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 8/31/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner