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DEPARTMENT OF BUILDING INSPECTIONS t
212 Main Street • Municipal Building '
Northampton, Mass. 01060 " ow
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 5I /IA/ 1 L I/f�c 117J, 1//z/ `i /146f21 E :1701,"-x/ /I �..G,�,C„
(licensee/permittee)
with a principal place of business/residence at:
3Y-O 411. 4--5 1., .-.__. i t'k JGrz67//1-7fli%2 t,jj4 (phone#) r--5W-76-22_..
(street/city/statPJ7ip
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:
/9e,:e./9'. -11-5V/Z.,0-itte Z wer/-0-D210 i zjih/
(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 Meet if necessary to include information pertaining to all occdradors)
( ) 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,a consuvetioa or repair work on a dwelling of
not snore 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 compensation Ad(GL1S2,ss l(5)),application by a homeowner for a 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 Department of Industrial Accidents'Offioe 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&ne of up to S1,500.00 andlor imprisonment of up to ono year and civil penalties in the form of a Stop Work Order and a
fuse of 5100.00 a day against me.
Signed�a.' / day of �-.J 7 i411. -2})).3 Far department use only
,j � Permit Number -
Afr / , .���1r ."f� �� 9 Map# Lot#
rgnatu a of Li.... - "ermittee
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman— 077279
License Number
268 Fora-r ,moo- 0. Southampton., MA 01073 6/21/11
Address 46 l I Expiration Date
11
/ .
� � 584-7522,__„^
Signat e Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer Road _ ___ 10/13f/f
Address Expiration Date
Southampton, MA 01073 _Telephone 58477522
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 1ifl 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, von 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„,,, TIsN . DESCRIPTION OF PROPOSED Ws R h k II *ii lb 11)
, —
— 1
New House ..J Addition Li Vt
Replacement indows Akteration(s) Roofing 0
Dr Doors 7.1
Accessory Bldg. D ; Demolition° New Signs ' I Decks : i Siding [ ) Other : )
9:i,:".' Dr..-2,(: zy, on :;z Pc c:i>0',,cd N 0';•k Bki-h 'c.e ou le( , 0 0 34.1'11 -4kAir-,c1( m_ (2 hav-/61_, C/ti nry4-
a _
,!,A i-j..-.ri,t1, -1 :-e ,...,yisl!rtp, her:.! ":11 .._ asiff,-,: riFlw :Iftri.r:e— 1r.ft,i "Jr: I
Ati:nitti:; %.arrdtly:,- ..vo.,..,;00 R ...IV ''11:,,II ^j ',.;.,V.A.•flit',7t l'el:., ..1,,.,
Fla:-s th lz:.Dd `,:; t!!,
63. 1f New house and or addition to existing housing, complete the following:
ti,,f, :-...! Dii:ic..1.-4.- Cc 7:11-n k 7w, 7-4n-r1:, ro—A r
R;Alinf'l i"•:* te.7;•7"F. q F7,..=iC:11 75r.1,./ ,Il", i: %t1.77•1n•i;' 1",oi i-i.7:tr:TC'"`..'F'
J r7G;rdy.ii, SI; '°4 t-'! k:i:L'i1,E1 ,:l. 1 It?..ic .',^.:,(1!'tf US.,,t,;)11 :)1''.,HPIS■1(/t!,
. 'c :- :J :::' •Ii..:ot !le i et r: e.:':,!..!:., :Jr 'Ncr„.:(itov.:,::, Nrw-tv a' e.ocli
p F-Fe;,y Cc:-%erri.,:tc:7-i ;7,01-7,1 ja7-..7-2 :t1,2Ck Enc,gy,ThitiL&Dn:$2 fN"r1 a'AECI,C:t?
lyf.t•' .:`i CC'Oik..Citcl
`.:•C■..7.'0.:ii,„ iiVI V.Nihil 1(X) '.t. hi v.•::,.,i .:•.rit:f)? Yes •13. li, r.,:::)nstr,.1c1..-Al w zt-1:- 100:et 1(..:',...101a :1 l't:•, N:J
.1 1
intl:1 f?, eel I Dor :.-felovi 'wi't er! iz,r.,i(*.
k ,,v 1, nu !de.F cc,farm to :h.,e 14,.!:Icirq: co:I ?::.0,1-,E, r:,,g„Lit IC'f,?
r
St.3:11C .": '!:* C ''..v Sew;-1 Pr va-k,,,, ,...el Cy Niter SrOrt y
[ SECTION 7a -OWNER AUTHORIZATION -TO DE COMPLETED WHEN
1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_ ....._ . ,
,(qf9i.)fl_l`Ic?,,p17Gi Cl Y] Etni k Sityei-' . , .a... Owlet r! ,''.'"- LuLject i:/ Ity
Steven Si verman, Valley, Hon.,_ Improvement, Inc.
M,..• Lc"' ,t"w el 1 7 L ',it:7S '.0.,ittt" ti; V.:A•,. .7.1.1hc•weC, ty, ihis 1.::-.,1'• hi: „•,,,6!:,•;r::1:10;•„:tir:,-1
:S-i'li.,iTi:Illrci: .`,f,";re r wok i
Stooten_Silmerman, Valley Homo Improvement.,__Inc, „v. ,;:...vn1-riArvi7f-1 Ac.et 1
!1,7-':...b., dr.:C 'ele i,-El: at "",.i.iiVititritS :MO infc4r-i..t;;;)11 u tilt for eRoir g aorr-cdtic:i ,.it;., yut: ,:inj iieurAv, 1,,) '31 . iie!,,i, 1,,,t iry
kr,mic..cps: .:nr..-!' belicf.
, ri.t„.7-cd .:-..cc!. `..1-: DE!!' ...i 2!7:1 ,;:::•iii tr!.::: :...'
Steven Salve 0, * .,,.. -
.._ _
r I r7"'”. 1, 4.----- V;6743 '
D:11.,
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/Findin ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded the Registry of Deeds?
NO DON'T , NOW 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 aqy proposed changes to or additions of signs intended for the property?YES ._
No
•
IF YES, describe size, type and location:
re: Department use on:41':',,;,;,,''':<� �`'� CI , of Northampton Status of Petrtit
I \`L� ,o\'� '. ilding Department Curb Cut/t rlveNay Perrnit,
�<`
212 Manioc,Street SewerLSeptic Avallal3 Ity
,:='��� Room 1N'�� /1Nell A�allabilify � �' '"� ��°~
M. �'5se` Northampton, MA 01060 w ets of `Er`� rural Plans
OeCdr 4'ts v
oe`�•r one 413-587 1240 Fax 413-587-1272 Plot/Site Pl
Other Specify '"
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:
2A �- Iia.iri Lc -e_- Map Lot, Unit
Zone Overlay District
Elm Si District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Y � 71 it .�,' 29 k jar) �--Cl Icxe �e f l�'�'�zsgv
Name Pnt) f Current Maili g A, dress:
�1 Telephone
Signature
2.2 Authorized Agent: teven Silverman
Valle H• � e Im•rov; � ent / � _ P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
�ll L JiJ 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 1 Official Use Only
completed by permit applicant
1. Building
10 06)0 (a) Building Permit Fee �S--
2. Electrical ' tal Cost
1) (�1 Construction on from (6)of
3. Plumbing Building Permit Fee
(b) Estimated
4. Mechanical (HVAC)
5. Fire Protection //
6. Total = (1 + 2 + 3 +4+ 5) �,�Q(� Check Number ��lod ��
This Section For Official Use Only
Date Issued:
Building Permit Number:
Signature: I
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1036
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 29 SYLVAN LN
MAP 35 PARCEL 287 001 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 V /-6 0
Type of Construction: REMODEL BATHROOM
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 OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
F 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
Demolition Delay
e
K
Signa _ • Buil.ing Official 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.
•
29 SYLVAN LN BP-2013-1036
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-287 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-2013-1036
Project# JS-2013-001713
Est. Cost: $12500.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 66124.08 Owner: MURPHY GREGORY R&EMILY R SINGER
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 29 SYLVAN LN
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:5/2/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM
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 5/2/2013 0:00:00 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner