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' DEPARTMENT OF BUILDING INSPECTIONS
• • 212 Main Street • Municipal Building \
1V �, ;
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L S G: 4 /z /5 / LVVun%2 Y1/ , /fOM cc l �P2/�1 14- 4 i _r
(ltcenseeipermittee)
with a principal place of business/residence at: •
3 U 4l vbz- --c kbF . k'S ! , 16 i<j - - 7/77/ 7a /=rzrrz ' / /if/ (phone #) h�f - 7522—
(strert/city/s'attip )
do hereby certify, under the pains and penalties of perjury, that:
0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
/9 /19" . mil 54//40 - ZG u) 5 G1 Z/////
/
(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 workers 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 era)
( ) 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 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
employes under the worker's compensation Act (GL152,ss 1(5)), application by a homeowner fora liame or permit may evidence the
legal ctatua of an employer under the Worker's Compensation Act
I understand thst a copy of this statement may be forwarded to the Department of Industrial Accidents' Offioa of Iosureooe 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 51,500.00 andlor imprisoemeui of up to one yrar and civil penalties lties in the form of a Stop Work Order and a
fine of S100.00 a day against me.
n
Signed 4r as ' / _ day of : J V (� YY, tt0 3 For departmental
use ally , Permit Number
/T / i4',/' JO WO Lot #
ignature of Li.... `ermittee
{ 4 e /t' ' ac € .
,jam ;tom ()$fic, tt to[n: tllTncf Afthirs and usiness Regulation
10 Park Plaza x Suite 5170
Boston. MassacIlusetts 02116
1 loi e Ir ipro\ tment Contractor Rcgistr° tion
t eqp it t cn 131945
Type Int3isr,rl
Enicalton 1011312014 Try 2323
STEVEN EN A SILVERMAN
ERMA
STEVEN SILVERMAN
268 FOIV1ER RD,
SOUTHAMPTON, I , MA 01073
pd:rte Addrens and return card, Stark reason fur change.
Address Hear%al Etrtple trnent LO t f'Ard
. t �a r aal� /44„....s4 License tar registration t;alyd for tndisidul use only
- HOSE IMPROVEMENT CONTRACTOR before the eAspiration cute. If fcsund return tot
Registrattorr 131945 Type ()Mgr of Corsi nner Affaars anti Buns R ulal n
0 Ez ioat cn 10113,2014 ind,vf r;at Id Park Plaza - Suite 5170
BAOSton, 4l t 0211e
STEVEN A S EVERMAN
r +
STEVEN S LVE M
259 FOVE R € r `< + t v �•
SOUTHAMPTON, h A 01071 t azlerseeretars Net salts! w About signature
6121/2014
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman_ 077279
Lcense Number
268 Fomer • - 'outha n, MA 01 071 6/21/1
Address t
Expira'3on Date
•
/ 1 /! i V 584 -7522
S; a Telephone
9. Registered Name irravement Contractor Not Applicable ❑
Steven Silverman__ - 131945
Company Name Registration Number
268 Forcer Road iOf.2 /1y
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 11 No ❑
11. - FIome 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 -vear 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 or
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
' 5. DESCRIPTION OF PROPOSED WORK (htek villis,,h1s)
Nw . „
1-Iew.e Addition J Replacement Windows A.teiation(f.j/K. Rootinc r
Or Doors
Accessory Bldg. DemoIitio New Signs " ) Decks Siding '; Other j
' 1 Pr() I EAH gli
; F ' - P /3) vt,33) .?
) '
Y n m 'Jr:
11•3,,F3r,',.; !,33..1:33t
6a. If New house and or addition to existing housing, complete the following:
, .,3u W."3 'y Tv
r& ■%" rt
° n :31aChEtC:?
-.E.—
7
. 1 --- 1.;;•,. u ch
va:IC7" 3.7.30; :C/c farm cc-7
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. C ;5;1...vv.! l'r v..atet ::::„*p ,
SECTION 7a • OWNER AUTHORIZATION • TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
7
a :
Steven Silverman, Valley Home Improvement, Inc. fAt
rT, , d ttf ff' 1i l:..1
3
:""d: ey' the f; R;;;;1[.33:24t1(; uv .1; ivy
LrCwir:Crf. nr:
Steven Silv= ,
Aiti
2a)3
74:
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT 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 ever been issued for /on the site?
NO DON /KNOW YES
IF YES, date issued:
IF YES: Was the perm' 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:
r
Department use only
L�
2013 City of Northampton Status of P iit:
fa : uildin Department Curb Cut /Driveway Permit
212 Main Street Sewer /Septic Availability
$ UILD� NG W � P O ��
p PION
N05al � Room 100 V tallNell Availability - z
Northampton, MA 01060 Two`Sets ofS ctural Plans
phone 413- 587 -1240 Fax 413 - 587 -1272 Plot /Site
Other Spec
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
(/L - : CZ -e (cL "i Map Lot Unit
44/ 7,c% (/./C)(;^ Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
411/ G/� / ' / Al L.
Name (Print) Current Mailing Address:
Telephone
Signature �� (� — fie 61
2.2 Authorized Agent: Steven Silverman
Valley . e Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address:
/1174
ApY- 584 -7522
•
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 t L)ry (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
i �����
Construction from (6)
3. Plumbing I ' 00 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection J\\
6. Total = (1 + 2 + 3 + 4 + 5) 1 360 Check Number jO e3 (0 f Q :
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0752
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 92 BLACKBERRY LN
MAP 18C PARCEL 132 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /j Q 3 p/ l P G o
Fee Paid �J�d 0 6 O `�
Tvpeof Construction: REMODEL KITCHEN
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 FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Demo :on Delay
ture of uil mg is al 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.
92 BLACKBERRY LN BP- 2013 -0752
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 132 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 -0752
Project # JS- 2013- 001293
Est. Cost: $31300.00
Fee: $187.80 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sa. ft.): 12675.96 Owner: MASON DANIEL K & SHARON WRETZEL
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 92 BLACKBERRY LN
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:2/12/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 2/12/2013 0:00:00 $187.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner