23A-206 0 4 _I
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r � DEPARTMENT OP BUILDING INSPECTIONS — _`_�
212 Main Street • Municipal Building o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L /1/Z Lsokr EN / /l%4-�77 l/ y 771 e9 G;#'» ,71, Z L
(li permittee)
with a principal place of business/residence at:
3 qo )/5 j. z)iij// 4 ,t/0,e/2f7rn," ; old (phone #) 561 `f - ZZ
(6 =1 / c i ty / stat e z Drab O
do hereby certify, under the pains and penalties of perjury, that; t `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)
( ) 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 Contactor) (Insurance Company/Policy Number) - (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all coatrartors)
( ) 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 throe units in which the homeowner resides or on the grounds appurtenant thereto ace not generally considered to be
employers under the worker's oxempensation Act (GL152,ss 1(5)), application by a homeowner far a license or permit may evidence the
legal stains of an employer under the Worker a Compensation Art_
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 seatre coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 21,500.00 end/or imprisonment of up to one year and civil pccattles in the form of a Stop Work Order end a
fine of 3100.00 a day against me.
Signed this . ii day of 7i -4 26,44 For departmental me only
�
'J ! Permit Number
'/ ,1 . 1 0.641 'zed4 MaP# Lot #
Signature of L • ermittee •
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman__ 077279
License Number
268 .�mer 'Southampton., MA 01117"3 _ 6/21/1`
Address ! / I Expiration Date
584 -7522
S;g at' re / r Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fome 10J1
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 lgl 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 -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 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.
I Iomeowner Signature
. 5. DESORPTION OF PROPOSED WORK h k II .1 pi's)
. .
Ni:..w HCW..e, ..... Addition Li 1 Replaouty Window. A, tel ation(0 :7 Rootinc, t
or Doors :
Accessory Bldg. .:1 Demolitior New Signs * ] Decks ' } Siding : Other
. ...
5- Dr.--,e,..14ro°. ,.ort ,;' or: j .t. ' 1 2- T Q-101 A Cerrd \Ai '''i (1 dIAJS 0 \r) ( 0
r:. '4 - o' , ...w.4 EtP !!!-!°,' . \ir , *.c...:11!R 1•1=ri: :If-r(...- _ '1,4., ----?' `1.-
,
.....t'.,tC(e,.:. " ;;:t7,..'Ll ;-: 111Fit:',.... t;O:rtibt: t '
: :'^tIta:"
62. If New house and or addition to existing housing, complete the following:
:)12 IC: ' i C'E :-Irn `; 7.. : ( ..„1.e. -, .."!.
1 4 (j...:."` 1 , . , ., , J" . . s .1 ',: :, i' 4 V1 -- ;..,i':' n. r: , .. 1 :: - ' C;(7,
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" s 4. .. I 04; • Fi4c,41 1
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e t--1::Ir I '..H'ir :Klie/ '4 , v.hel.:
1
:11: Id 1 cc f,'$1 tC: * ,.s' BUtPimp, :11,1 ?w 4.,..htiC.' :t? 'Y 2 :. ND
. Sl.„1:73C — Zrik c '.y Sew:;-.1 Pr 'j CA:y
SECTION 7a - OWNER AUTHORIZATION • TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• as 3.....-.cs ct *.-•-... 1,.1Lct 1_, `:_f_f t:d
Steven Silverman, Valley Home Improvement, Inc. ::, .--,:.t
rt .,...1 2 ,...-.Hr , i , 4 I -- -.I -4,, 1. v. „:1-
Ali ro. t! 7,- :r, Po. 1 :: roi.., *•, ..:c.'illt.: -111 't
Ar
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' Illiir
11111.11111111111111111111111111111111111011111111111111
• Ste:sten.....Snoterman, Vail ey_Horne_Imprsty_ement.,..._Inc,..- /Alit' g , if' - : 11 4.,:i'i. C
i:2C: NC. 7 . - 1 7 .1 7Y„." : '2rIC r t ;, e - the tbreRc..Ar ;.-; ,t;ir = ;,„Itic. tr ','Lie ..; oi !,, r :tr.:, !!, 'he !.,,-- „' L... it y
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Steven Silverman_
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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
Fill:
(volume & Location)
/
A. Has a Special Permit /Variance /Finding eve f6een 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 tyfook, 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 arty proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
C
I
•
M
,6 0 IA ki 1/1 CJ(G
.,
Department use only
' City of Northampton Status of Permit: r
.'' :wilding Department Curb Cut /Driveway Permit
10>j �1, ,
212 Main Street Sewer /Septic Availa ty
� �, ��` Room 100 V yke,r / Availabilit � w.°
0 . ; hampton, MA 01060 TWO of°$tAictural Plans ;L
,,•r , 4 13-587-1240 Fax 413- 587 -1272 Plot /Site P1 :-
dr �■ Other Specif 4.
• ICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING f
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
C() /56 Z s , Map Lot Unit _—
f " C27/ /7 ('' , l n / 4 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT ,q /�
2.1 Owner of Record: (3,7 / �.L_� / CJ-'!
wry/' ,5/7/// // 7 77//%U/Z / /US' on- 27 Z.; J
Name (Print , Current Mailing Address:
■te■
:N, r.,. 11.04 ".a .• Telephone _ �j . /
ature N..../ C70 / , ` 2 < �/
2.2 Authorized Agent: Steven Silverman
Valley Home Improvement, Inc. 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 (fvO (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)
`` (ZI) Check Number 30 8 a ''3 c
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date I
90 BEACON ST BP- 2013 -0283
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 206 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0283
Project # JS- 2013- 000463
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 18905.04 Owner: SHEA LAWRENCE D MAIL TO: THOMAS M SHEA
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 90 BEACON ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON: 9/12/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL 12 REPLACEMENT WINDOWS
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 9/12/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner