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DEPARTMENT OF BUILDING INSPECTIONS .‘ =�_
•
212 Main Street • Municipal Building
Northampton, Mass. 01060 _',.
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
si211iV5/L///acs?/7/, //Z/__Z-i4.1 //OM£ .J2/1 fiZZ4T,J1tCC_.
(licenseiipermittee)
with a principal place of business/residence at:
3 y-0 4,11/ 1-5.:'2 r`_-Jim ,,/1-4 -7,/-7.-M7/1/73/1 77`,i//I/4 (phone#) :- /=75 2._
(strmt/cityrstaie eior
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: `
. (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 s3xet ifnoees:vary 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 maintenance,construction or repair work on a dwelling of
not more than three units in which the homeowner resides or an the grounds appurtenant thereto are not generally considered to be
employers under the worker'sootnpensation Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may evidence the
legal statue of an employer under the Worker's Compensation Act.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents Offroe 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 S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fiats of S100.O0 a day against tne.
Signed ��' day of,i( ,!/S i t�I Far use only
F . Permit Number •
.4.0' / W/ ; , // 1- 4 J/
Map;!s Lot#
ignature of Licensee/Permittee
(„Y tie /1111
usi „
,
cat Consumer A tfinrs and 1 ness Reoulation
10 Pa:k Plaza - Suite 5170
Boston Massachusetts 01116
Home ' •
( tnt Contractor Reotstratton
RegiSication: 131945
Type: individual
ExpiratiOn: 10/13/2014 Trtil 232370
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD.
SOUTHAMPTON, MA 01073
Update Address and return card,Mark reason for change,
Address Removal Employment Lost Card
opc 1i c.4
i.
tft
Office of Consumer Affairs&114.64aesstdation License or registration%Aid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 131945 Type: Office of Consumer Affairs and Business Regulation
Expiration: 10113/2014 Individual It)Park Plaza-Suite 5170
Boston.MA 02116
STEVEN A,SILVERMAN
STEVEN SILVERMAN 11 ,11
268 FOMER RD. /11/
4.\,:,a / 7, X 1.-
SOUTHAMPTON,MA 01073 Undersecretars Not valid wthuut signature
.`"
it741
'vTis
I !
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman_ 077279
License Number
268 Fo.!=r Ro= • _Southamptmn4- MA 0107 3 �_ 6/21/1'}
Addre•.s Expiration Date
ha Mi 584-7522
S"s- �ture Telephone
9. Retistered'Home Improvement Contractor: Not Applcabe ❑
Steve_n., ilverman_.__ 131945
Company Name Registration Number
268 Fomer Road 10/13J
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 1:i1 No ❑
11. r 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 he 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 1 aws and State of Massachusetts General Laws Annotated.
Homeowner Signature
• .7crtzti s. DESCRIPTION or PROPOSED WORK cchtrek all220eic700
New Hotze `.....: APdition J Replacement Windows A teiJtion(L) r., i
1 Rooting
Or Coors ::
[
Accessory Bldg. 2I Demolitio- 2 New Signs ' I Decks ' 1 Siding f I Other . I
N (..) u.,11,, ,----r--
ey..).,..r AsPAA-LT Si--6,;,(:, -rtf..; ,),.) 1 ,--
_......____......._..._
'4'1',,,,.'ILI,: .,,,'L:St:.'::: ,tt.:'k j.# ;•:. ...:r 't{",/.T., e..,1 t.:1(F.:: t .,L
71:,' 1, !.‘,:',.:1:'1,':;: 1:0: !,::* ■'''t'.
621... lf New house and or addition to existing housing. complete the following:
,T:
hK.:
jr.,:- .,,..! '1; .. „ ;-- ' :, t 1:.• ' p,-,t. , .."-,r. t
i ".: '': :.",H.' : ' `.,te't.'.:■.
1 *• VC*■'‘........t t..;' .e..%1°, ,"'"::: i 1 ;,,A. —.., .,,S1 ,t'.. r,
,,-r:y '," k -5-.....'1 t.F..7C- 7...;...+,--: i. - :'. %.t7 :7.7 :,7...,
1 r..):: `; ..,: e.i.-.1' -;'.f,...tt? ''':',.1, N„ ;;..t f: Mc..g.t ...H 0. ":. I :00 yi 1,:.,:;.111 .:
,Dt. t.,;-,,,•:...., trtl'ttkt.(; i,t.y.f.!
, %'.' ! nuitt.t-t.:-; ::(t• f..1.rm
. f.::.t.i.".A.7. -e• I:.______ ,::. ',1,4 F.,:r.,,':.,-r f'r '.,,:,:..i: v.,;',.. ' ",.,,: ",y 17,‘,"-..t,,,,, ',..:.-,;.' y
SECTION 7a - OWNER ALITNORIZATION TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-------F
... .. .... ...
Steven Silverman, Valley Home Improvement, Inc. ....7).-,:... :-.),
" I
rr.. L': :r , ' ,...1 ■+ ",,,,,;',--.-.,:-.1, -1 0° hl v, ..,1, e- ,i “;-,,°P-,, I 1...0 -., :q,,,.
I
1 ,zA,,,o Lc...h.-_--c■ ,..At. .^. ...A;
SteyenSiamexmans Valley_liorite_laproiceraent...,-131c„._
T_tc. ::f tt.:t -..•':I, 7 7 t.' :1 it irArle..-11:.) :.. iC 1,-E;:i--i-'. :At u- t',,iti f..,x,.:.F.,„11 ;: .1,"01. :-itIC,* „:r^.1 ,'1.1,..1 ,5'!*,, 011,-,,,,r ..tr..% 1:, ;.o.-: '..t.--.`. 1,' it ,o
t ..t.A.:-.,:i ...-c;_' t:,-.. t...,:. • t, ,• J t,:t.. L; ,v„, ,..: ;.,r,.. t,,, -„
Steven Salve lian
I Jr
...
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 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 any proposed changes to or additions of signs intended for the property ?YES_
No
IF YES, describe size, type and location:
�\\I \) \ Department use only
��C . , ity of Northampton Status of Permit:
a-
520` B ilding Department Curb Cut/Driveway Permit,,,,,\ ,,.'4'
12 Main Street Sewer/Septic Availability , F
;Fc',,, • Room 100 War/Well Availability
"° MP MA 01060 tWo'Sets of Strdctural Plans k :
V NpFgPN,pSpN, Northampton, a
O' phone 413-587-1240 Fax 413-587-1272 Plot/Site Pla
Other Specify : _4'`
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
: 3'1 5)-alC S.-/-Y't t,f._ Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ch r15 Pay,-1.56 1- 302 c1 nn t „Sin/4-1-1 eV ,Sh.ic S)-reel, l'1ovl1- , r, -.,-,
Name(Print) _ Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Valley Home Improvemen , Inc. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
Air/ i Ali J 584-7522 --
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Oniy
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (5) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) t0 c)t)C> Check Number 3))..gL `�' _
This Section For Official Use Only 7
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date .
134 STATE ST BP-2013-1163
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:ROOF BUILDING PERMIT
Permit# BP-2013-1163
Project# JS-2013-001095
Est. Cost: $10000.00
Fee: $35.00 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:6/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 6/5/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner