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" DEPARTMENT OP
BUILDING INSPECTIONS -
' =._�"j-
212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE Ar'E.WAVIT
I, /1/ 1-50 SW //)= V, iL P' L .!%�n/' 'v'' A/ r, _Lk L
(license&Jpermittee)
with a principal place of business/residence at:
•
3 `f o JVf S Lb � e- lii a/D,�217, -; il1A (phone #) - 7Z
(street/cit s to zip) 6 / a
do hereby certify, under the pains and penalties of perjury, that:
1 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 Cornpany/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 skeet ifnecersaty to include information pertaining to all cc radors)
( ) I am a sole proprietor and have no one working for nee.
( ) 1 am a home owner performing all the work myself.
NOTE: please be aware that while homeowners who employ persons to do n intenaaa, communal or repair work. on a dwelling of
not more than three units in which the homeowner rides or on the grounds apputtanant thereto are not generally considered to be
employe under the worker's eoropeastion Ad (GL152,ss 1(5)), application by a homeowner for a license cr permit may evidence the
legal statue of an employ under the Worker's Compensation Ad..
I understand that a copy of this stain may be forwarded to the Department of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverages under section 23A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil penalties in the form ofa Stop Work Order and a
fine of 5100.00 a day against me.
Signed this . / 5 7 6 - d a y of / ' 20/4 For depirttnenal us: only
7 ) . ,I „, g-244 P ermr Number
Lot #
Signature of L . . -- • ermittee
fte 12::10 frit& it-weal1i
()nice of COnSIATTICr Affairs and 1i ttess Reculation
10 Park is - Suite 5170
Boston, Massachusetts 02116
11orne Improvement Contractor ReLnstration
Pegmtratton 131945
Type indeocluat
Exceatton 10/1312014 Tr 2,3,23
STEVEN A SILVERMAN
STEVEN SILVERMAN
268 FOMER RD,
SOUTHAMPTON, MA 01073
t pilaff iiddriess and return Ci tit Nlark reason fur change..
al Renewal f mployment Lost card
,,,041.0k-Aaw.4
4firt ( oontrorr %Moro PloktusIltro,o1A Non t-irrOte or registration sand for nubs 1414,11 use unls
1 -HOME Ifi4PROVEMENT CONTRACTOR before tie expiration date If found return to",
()ffl re of Consumer Affairs arid Business Regulation
10 241. 1 Registratioe 131945 Type
10 Park 1 " 0
Expiration; 101130)14 nch 4u1
Boston. MA 0211n
STiVEN A sa.veRAMN
i 4
STEVEN S:LN'ERMN
Zen arOM AUs fl /11
SOUTHAMPTON V1A 01071 Not %Aid without signature
h.^
'T •
617, 1.!2C't
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman_ ___ 077279 __
License Number
268 Foo T R•t; • • it • • .. MA 01 071 6/21/14f
Address 1 ! /1 Expiration Date
1 1 � 584 - 7522
Signatu e Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer Road _ 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.
I
Signed Affidavit Attached Yes X 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 tune, 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.
1 homeowner Signature
° r7CitON S. DESCRIPTION or PR,,,,OFOSM: apittic11110
NeW H 1.1t.L' Aedition Replacement V*it devo& A teotion(!. Rootinr,
1 01 Doors : :
Accessary Bldg. Dernolitio7 New Signs Decks i Siding : ; Other I
.".•(; • / k 071 06 — 0 CNAIZE TO 'eArritli ___10 Skac7tAce 4 L
\15 (-1 . 1 ( •
%;..rkttl*:. 11 t
• V,
62, If New house and or addition to existing housing. complete the following:
tt
1`," f F ••••it .;!" t :71.` F
,V.r1LhE:C.?
r • r- ,"
-*
. ;. ej U WeCKI!. r.tr-
rI; - servz:tc. --, ia an:Q ftirn tctcc
• I th: t):: N.. w :OO
mt.; t:i ttr: w1:1 i.
^'N nu f•, c e R'11<' ;,11:1
. Stuc k C l'r ":".1`.9 voater y
SECTION 7a OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• as :iv.
--hi Seven Silv an Valley Home Improvent, Inc. rfin
Ste_v_en Stiverman,„_Malley_Horme_Impr.oxement,—Inc_. , /Atir,f 6/i-1 Atht
t ir2c'17f 1 f :jf t tr the foRti.:'Dit r
rnC• hI
I tr:',
Steven Silve
-*it!!!
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 1/
Fill:
(volume & Location)
A. Has a Special Permit /Varianceinding 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 contain 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 ary proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Department use only
RFCENETYcl y •f Northampton Status of POO
uii� ing Department Curb Cut /DrivewayPeriit
2 2 Main Street Sewer /Septic Availability
J Lr L 1 2012 Room 100
1N�
N e r /Well Availability � _. -;
orth. mpton, MA 01060 "Fwd ofs#,Octural Plans
DEPT. nT A m •
NU i 4 $ MR , iMd
RTHAM� i '3.58 r -1240 Fax 413- 587 -1272 Plot/Site Pl
Other Specs
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
3 57/772 J Map Lot Unit
r /l,:, Z7,*97 /7) Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 1 5V 5/777Z:
-�'T ✓
Name (Print) Current Mailing Address:
C1...)(. `� ( 1 -* Telephone 7y6
���
2.2 Authorized Agent: Steven Silve ' an
Valle Horn. m.rove3-nt _A, 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 ? 4 / OW (a) Building Permit Fee
2. Electrical i G l (b) Estimated Total Cost of
t I J! Construction from (6)
3. Plumbing ' 2 LC) (p-) Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection -y -
6. Total = (1 + 2 + 3 + 4 + 5) ' L� O/c..�� L) Check Number `3 1950 �� —
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0660
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 134 STATE ST
MAP 31B PARCEL 130 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid & 0/
Typeof Construction: REMODEL MASTER BATH
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
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
- u lition 1 - lay
/ /
Signr o Building Officio Date
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.
134 STATE ST BP- 2013 -0660
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 130 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 -0660
Project # JS- 2013- 001095
Est. Cost: $28000.00
Fee: $168.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 4007.52 Owner: PARRISH CHRISTINE M & SUZANNE SMITH
Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 134 STATE ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:12/20/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL MASTER BATH
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 12/20/2012 0:00:00 $168.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner