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- -- ---
Valley Home Improvement, Inc. HILDY DVORAK& RAY JACKENDOFF
arimmigt I
340 Riverside Drive, PO Box 60621, Northampton, MA 010b2 TITLE: BASEMENT SCALE: DATE:
Office Phone 413.584.1522 Fax 413.585.0820
DRAYNIN BY: 1/4= 1' - 0" 04.08.2013
Find us on the web at : www.ValleyHomelmprovement.corn --- - -- - ,
_________ -- - ------—-- - -- - -
ottAMp2.
4) 41051Vila 9 o 8 QiZt 'f N rt11&ntJ4t n * L_°�
"A
9 g i1v1 jd� asaACflnsetfa Mlle=
'W2} DEPARTMENT OF BUILDING INSPECTIONS = r -
212 Main Street ' Municipal Building _
Northampton, Mass. 01060 a.'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 9T b'e,!51 L l/Y-114M7' vi, 1///Z LF' //LOM f 71/1r 1/S —47— l.C..
(licenseeipermittee)
with a principal place of business/residence at:
3, ///' I 4G .ei4 ,,/(-) 7/71mfl?7»Z,.'jr9 (phone#) &=75-02_
(strert/city!s'atJnp)
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 worldng on this job:
/1G-i%_, -/tsp iez r,0e/7-5:0211i- Z/1!//
(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 Daze)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all contactors)
( ) 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 ref inf'nanr.,comtruction'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
employers under the worker's compensation Act(GL152,ss 1(5)),application by a homeowner fora license or permit may evidence the
legal status of an employer under the Worker's Compensation Ae
I understand that a copy of this statement may be forwarded to the Departrnm2 of Industrial Accidents'Offioa of Insurance for the
coverage vrri&catioo and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
comisting of a fine of up to$1,500.00 and/or imprisonment of up to one yore and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against me.
51" N , -2--°)---3
Signed41r' _day of �;�►� f� For departmental We only
0 / + Permit Number
I'c' ;/4 / ✓ G 1!' ; >' Map# Lot#
ignature of L' ermittee
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Steven Silverman __ 077279
License Number
268 Fo' -r ;o-•, • r , - n . es4 14k. 01073 _ 6/21/1
Address /f Expiration Date
/��/ /6-64'_7522 �.
Signat - Telephone
9. Registered Home Improvement Contractor; Not Applicable ❑
Steveilverman__. _ 131945
Company Name Registration Number
268 Fomer Road _, _ 101_13/M.
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 ]ifl 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.
Homeowner Signature
'
.'r:CTiON 5. DESCRIPTION OF PROPOSED WORK (check nil opplicohlt)
! New House :2 1 Addition Li Replacement Windows Alteration(s)0 Rooting
0
Or Doors "A
Accessory Bldg. 3 Demolition° New Signs ; J Decks : ) Siding [ ] Other . ]
......... _
3-ief Dr-x-rx, on r.:!. rr:pos,rtn it'ilo*,.) VA-ig.,,-.f) VC.LTivi P)AcgThenit .1\)(?,■A./ 0./rAff4 S./A 6 , 6,42kiss,,,q17_,, I
!ie. t-riqtr1 8 hrInn.:4orn Ye; X_ No Ar-,nxtp new nerlf00-t- 'ffti —15 No 2 Iluppreil
:.ttailiie..: Na7totive Re.owitir,i; ...tifi-lisheJ Lktrtiert Yet. rk,
P13-:; Attazhed Poi'
6.3. If New house and or addition to existing housing, complete the following:
1
pl torifIcInE, . C.7 e "-am ly Two rarntl:,.. _ Ot-er
e.ach •ar.i:y tint: Nitrnne" cit ritce,..'et.
a:ta,chec2______
d FrupA, Sd4. re tcct,v,e ul ilew .,o11.°:,Iv,./I'd ::./r1 Di-r.ell-,Ii/l';
1.'1'7...
1._ Yethoti Of "leatuie I r ep -!!...-.t;!.) or WCOdt.ttovt!.*:: r\1V of (loch
, E F-erEy Ce-servc,-:Corp ia-:c. Nizsiztleck ErteTy ialribranze form attact-c0
i.,,,,. , :)1 (d-f,trt,ctici
. '...)o,Ytt,tr,..;.:tis.„. iwittn,i 10D 't A t.....,;trik-h? Yes Ns:). li, citAi5tract .,111 w:t,n 100 yl, lt,i,:,:',44,11aai Ytt, Vt:i
n-ledt :! c:e1:,,,Is 1,:)Ot. t)eln.) 'Irwieo I,-.1dE..
k ',VII :.)o ILIr F. cortorrn to :tie BieiC:iftp, :Ind ?-,-)rient3 1-4..21atio^f,?
L SiTtle 7a•*, Cy Sewer Pr vate wel :;:ity water SKI)y
SECTION 7a -OWNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,
, \-\‘\(VA 7c)\I prc0e._ a c\c`■ c<0,AAcy,c...1-<\ 7.3),(Y.....eoc\c-)c\--(c , as 0,...ner d t-t: suLicct F.,, ptlity
y otnrIn7P. Steven_Silve 'I= ,Van 1 Home_ ImprOyament, Inc.
rr! ' Ur_a-Tr r. 01 --n,,,te,,, -tf:,,,t,../ .-1
w-A t:th wed fl 1 T. b--1';..: r1 :; ,)e,rrit rrO,hcat .:,.1
C
Stit,,t-a-Are cot roe, ifir. _,Ite
_Sleyen Silverman, Valley Home Imprstvement„ inc. , ,-.1,-, ,),,yrieriAu1ri,I761 .A.Eftnt
nr-eby dr.ctue thiv. •,nt: ..,aterric'tt..., :_mci inforrvittrod o.7 the, foreRoirR appl,cdtion ::..re t•tle (led occuote, t,,-) .tie t>tt,t, e1 try
trcwicepe :nd belief,
l',,I:Ted ,.:-c ' :1-..r: Da,r,_, arid t.',:'111 tin 0?
Steven Silverman__ . / i
. Silverman _
iii/,i t Nx-r,:t.
.,. _ _
.4..;,,,.:, ,_,...f,i,0, :,,le, Ar.,,,r! /j,/
/
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) �
r
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findi 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 KAOW 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 arty proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:_
RECEIVED
' Department use only,,
APR 19 2013 City of Northampton Status of P d y
J Building Department ''
epartment Curb Cut/lrl 1 V�3a it
DEPT.OF BUILDING INSPECTIONS 212 Main Street Sewer/Septic'AAvai a
NORTHAMPTON MA 01060 Room 100 `fiery/We11 Availability ''" ' -
Northampton, MA 01060 Tom•Sets o �ctUrai Plans �'a
phone 413-587.1240 Fax 413-587.1272 plot/Site :� r� t gig, '��
Other Spect ,Y ,, �
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:
‘�n I (3('k1'1 tat Z (--, Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\ orctNC— CiANck C . cLCkenc\o q cl (-lbcV n c)\-c-ee+- , =1mCa� M
Name(Pr' t) / 02
Current Mailing Address: ' i8
Coll - � `k ��39y
',PI i( � a �, _ ,i I Telephone
Signature
2.2 Authorized Agent: St-ven Silverman
Valley Home Improvement. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
1 iii 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building f!1 (a) Building Permit Fee
2. Electrical e5� �- (b) Estimated Total Cost of
/ J��'� Construction from (6)
3. Plumbing Building Permit Fee
,I 1 7
4. Mechanical(HVAC) �,
5. Fire Protection ,3/l 6' 6°
6. Total =(1 + 2 + 3 +4+ 5) ,` '�C0
Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-0961
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 177 NORTH MAIN ST
MAP 16D PARCEL 017 001 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 il 36.60 (� /l''J
Fee Paid XD l
Typeof Construction: WATERPROOF BASEMENT,NEW SLAB,BULKHEAD DOOR&2 REPLACEMENT
WINDOWS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
4 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
41 72-4/13
Signature of Building 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.
177 NORTH MAIN ST BP-2013-0961
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16D-017 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-2013-0961
Project# JS-2013-001607
Est.Cost: $19500.00
Fee: $117.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq.ft.): 18295.20 Owner: JACKENDOFF RAYMOND&HILDY DVORAK
Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 177 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/25/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:WATERPROOF BASEMENT,NEW
SLAB,BULKHEAD DOOR & 2 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 4/25/2013 0:00:00 $117.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner