03-029 1
eels tzi 'a O " " "` ea / � ' �` ' J = .
i
Office oi�C"OfsutT1.l Affairs and Business Retzulatien
.� a i , 10 Park Plaia - Suite 5170
Boston, Massachusetts 02116
Home Impi velnent Co tr etor Registration
Registration: 131945
Type: lrtdiv dual
Expiration: 10/1312012 Tr# 204690
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RCS.,
SOUTHAMPTON, MA 01073
update A€i €tress and return card, llarlc reason for change,
. Address - Renewal - Employment Lost Curd
.:...... ".
Din— :,iii ein,c,iii C1 t G101 2'€a
Office of Consumer Affairs & tictciness Iteh/,litatiiin License or registration -valid for intlisitlul use only
I E HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
_fRegistration: 131946 Tyre. t)flice of Consumer Affairs and Business 'Regulation
*r : Expiration: 10/1312012 Individ al 10 Park I'Iazt -; -Sallie 5170
4 " Roston, AlA 02EI6
STEVEN A. SILVERMAN
,,;/
., , , ,/
STEVEN SiLV ERtiiAN '
266 FOMER RD. . r ...__. ,
SOUTHAMPTON, tvl 010 73 Vridersecretaary N €, valid witimut signature
i..
.. ALissasttsi its - Department € ;f Pu €b r at
ts;l t;s
l w,11 al € f BuiEtliat +:att;ttiolts and StAruL3rit..
Construction 'Superviso License
Licervisei CS 77279
Re stxrtett tu:
STEVEN A SILVERMAN °
268 FOMER E RD
SOUTHAMPTON, M 010 3
u ---.."E ..ef. E T. p - u AVOW 6/21/2014
$ r;: 26868
t
...,inz ai *i n
, t
,0-,.m,.." p
9 A '' l 'J x of iI &ntp tt7i = *= $
B i., � �, ; SA assad jnsetts =_ ` —
fi DEPARTMENT OF BUILDIIIG INSPECTIONS
• 212 Main Street 'Municipal Building '
Northampton, Mass. 01060 es '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 4/ 1$OXf Eiv /,- T"` 1, fl , e_ ,/---0" '// T L
(licensee/permi ttee)
with a principal place of business/residence at:
3 `f o ! el vz,65 i .6 2., G) ,/ / �O,"71 , 7", ni (phone #) ''',8 V- /, ,
(street /city!stai trip) 0/ 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:
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, suction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appstteannt thereto are not generally 000sidered to be
employers under the worker's compensation Act (GL152,:s 1(5)), application by a homeowner fora license or permit may evidence the
legal status of an employer under the Worker's Compensation Ad.
I understand that a copy of this statement may be forwarded to the Decertmer d of Industrial Accidents' 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 $1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
farm of S100.00 a day against ter.
Signed this / ay of ! "
$ d - 201. For departmental use only
Permit Number
I / ' . J,./Ati ' /' Map# Lot #
Signature of L' - • ermittee .
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven S11VermaTL_ _ 077279
License Number
268 ..me l 'o -_ , wit Expiration MA n1n 73 6/21/1I`
Addres ; I Expiration Date
/ 584 -7522 _
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer Road 10/131)z
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 X No ❑
1 1. Home Owner Exempt
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 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
CTQN 5. DrSCR1PTION Or PROPOSED WORK Ech.;k u
Nev.. HC1.1!...L ; Addition LI l Replacement Windows IV tetation(OV Roof inc fl
Or Doors
Accessory Bldg. :1 Derndlitior!D New Signs j Decks Siding !: j Other
ori ";' IX' WC: . C t f ltU "f - Y.--
P' 1
(CM 'I „,to ,A53 to +1
y
tp, "iftft•r:i"•,""'
h.,
Ftr •'^t1071.7 POr
6a. If New house and or addition to existing housing, complete the following:
in y 7
• ...;•."/ • ,^4,:t":
r„kfri
crE r ecKh Li;": f u ti
E ';" r-r Enc-gy form
1 ti
U ti i tIn i! I ies I ( .:;)t1Ste„litt 01 I OD yl
I I rot I t f ;1(1E'
;:m 16 CC• fDril tC„
J s C Pr ve Ve.e,1 v. teT
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/
/4 as Owner LLIt".?: t p,'DcAtty •
h• ,tut''`,r171 Steven Silverman, Valley Home Improvement, Inc.
r' iIf I „ h:
62e-6 , -e—e-
St,„! 061er
ate_venaily_exman, Val1eyJzIorae_1.mgroyement,Ing_. ,
'CIC, 3 thti r'ORIF,,c1.1t ;11'; t g
' nt br.!I
z!-
_Steven Silverman_ /
/ 1 (?/Zz5-
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 the 'egistry of Deeds?
NO DON'T KNO YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a .rook, body of water or wetlands? NO DON'T KNOW
YES -
i
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:
RECEIVED
Department use only
SrP 2 7 City of Northampton Status of Peemit:
Building Department ,
Curb Cut /Orveway.Permit
OCrT C ,,U1 ir\ 3INSPECTIONS 212 Main Street Sewer /Septic Availability
NORTHAMPTON, MA 01060 Room 100
---- — Warr /Welt Availability ,
Northampton, MA 01060 Tvvo Sets of S ; cturaf Plans
phone 413 - 587.1240 Fax 413 - 587 - 1272 Plot /Site Pld
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
/Z /: . :()//c/ / Map 3 Lot ( ? Unit
C J /,'__M/1 ,, 1 417 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: l /01 -1U &Lj f_ ..1
- Name (Print) Current Mailing Address:
A " i ez, -. 4 0 4 o _ Telephone l C _ �- 7
Signatur
2.2 Authorized Agent: Steven Si verman
Valle . , a Im.. ov- l L_L. a P.O. Box 60627, Florence, MA 01062
Name (Print) � if Current Mailing Address: ���� � 584 - 7522
Signatur- Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
l� / / (Yri) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) ?CO 00
5. Fire Protection V,5 �'
6. Total = (1 + 2 + 3 + 4 + 5) `# CJ, p5O Check Number jbt Q 1
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: ���� i
':flUfl C. --issi.n nspe . • Buildings Date I
591 COLES MEADOW RD BP- 2013 -0362
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 03 - 029 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0362
Project # JS- 2013- 000590
Est. Cost: $6850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 131945
Lot Size(sq. ft.): 281049.12 Owner: REITT PETER & ROBERTA
Zoning: RR(100)/WSP(100)/RI(32)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 591 COLES MEADOW RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:10/1/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE SHOWER STALL
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 10/1/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner