24A-090 (2) 15 NAM
fM$ Q t af X #l &nt1 L r
DEPARTMENT OF BUILDING INSPECTIONS 4 -1.41_
212 Main Street • Municipal Building
Northampton, Mass. 01060 ='��
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 52-- / /IV S/LVfX4/ 7��, /dUF' h t 711 E 1/� 1/Slitecn%i_ritC..
(licenseeipermittee)
with a principal place of business/residence at:
v ,6/vu / s :. 1-2,-- r,�>Gi�<7/-7 7/YZYZ,.l,4 (phone#) :� �f-75"Z .-
(strcet/city/s' to lipc
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:
r9Gfi:& ,-&.,sv to use ,�021 izil j //>
(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 sheet if=canary to include information pertaining to all contractors)
( ) 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 vibilo homeowners who employ persons to do=Mumma,constniction 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 workers commeasation Act(GL152 as 1(5)),application by a homeowner for a llama or permit may evidence the
legal status 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 Amid Office of Insurance for the
coverage verification and that failure to segue 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 andlor imprison of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against me.
"2,0)_3
Signed as' ' day of J i' ,(4�, For departmental use only
/ Permit Number
/� (A1.41 ,/ /`ifs ,' i/, / Mils# Lot#
ig ature of Licens- eef?ermittee
f t f C te ' e
• Office of Consumer Affairs and 1 usiness C e gtliation
10 Pa,.k Plaza Suite 5170
Boston Nlassaclhusetts 01116
Home Irnpro_, r e t Contractor Registration
Registration: 131 945
Type: Individual
Expiration: 10/1312014 Tr# 23237E
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER R .
S OUTHAMPTON, MA 01073
Update Address and return card.Mark reason for change.
Address Renewal Emplo%enent lost Card
oMAfk,,r< �zlfd itia„4„..,ae4o-Joett License or registration valid for indisidnl use only Office of Consumer Affairs& 1# mess Regulation
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: :131945 Type: Office of Consumer Affairs and Business Regulation
'417I „ Expiration: 1011342014 individual 10 Park Plaza-Suite 5170
Boston,MA 02116
STEVEN A.SILVERMAN
F
STEVEN SILVERMAN '
_, z Jr
268 FOMER RD. ieit r
SOUTHAMPTON. MA 01073 1"adrrsecret.ers Not valid without signature
•
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman_ 077279
License Number
268 Fos a Ro-
��� • ��• n MA 01071_ I 6/21/1'x`
Address V./
Exp ration Date
.. 584-7522
_..-------
Signatu e Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
Steven Silverman_ 131945
Company Name Registration Number
268 Forcer Ro d 10/13//t
Address Expiration Date
Southampton, MA 01073 Telephone 5847522
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....... No 0
1 . - 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 stud!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, von may he 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
• .- DTtCti S. DESCRTTiON OF PROPOSED WORK (cht-ck AU s.ohlt)
Nu:ve Ficen.e I:. i Addition J Re;Aacement Wirdows A ter:Ition(s i Rootivz 1- ,
[ Or Doors ::
Accessory Bldg. :i Demolitio- L'1 New Signs ' 1 Decks ' 1 Siding :., I Other I 1
i *.' - 'it Tiri
, .4,411) . PL ) t.,‘)wIstoi-,) c i _ e_._
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71:1—", ^';:,;;.;,17..;;K:.;.; 1: i: !:;•It''',
6,a, If New house and or addition to existin housin•. corn.fete the for lowinl:
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fl "il ";? :;;•:"--!---W. f•• ,;:f :■t;t," ".,' ;! "t'Att.;!.
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SECTION 7a . OWNER AUTHORIZATION TO DC COMPLETED WHEN
1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.,... . .
±--5-00..ontlk... t!),r cte,„04Duct.) , as
:,.,, 11— :..,,,„,, Steven Silverman, IT/Alley Home Improvement, Inc.
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3,..°C FU2 :-.,:-. •I'',°: ',`,..,:licrri,,T.z... :.fic 1,1,',1r-i"... ',,rt og:'` the fh,tei.:Cglf ii ,Ihrg; :,.iii g re • ge gi°;:j 0.t.;,I tt,g-, .',; he „g■g-gg„. i: e y
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St even Sil erman ,„.,_,,,, _ , I ., ____
/
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 iss .ed for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of I-eds?
NO DON'T KNOW YES
IF YES: enter Book 'age and/or Document#
B. Does the site contain a brook, body of -ter or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or nerd 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:
1 i RECEIVED
JUL °1 9 2013 Department use only
l y o Northampton Status of Permit:
DEPT SP
OF BUILDINGIN4,: Il:"i7V g Department Curb Cut/Driveway Permit
NORTHAMPTON,MAO;asp7 Main Street Sewer/Septic Availability
Room 100 W�er/Welt Availability «°
Northampton, MA 01060 Two Sets of Structural Plans .,
phone 413-587-1240 Fax 413-587-1272 Plot/Site pialY
Other Specify`` ,,,,._,
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
1 ptt-k tvrt Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
O Ctrs -c\ k Yo r_i.r∎ryrc.- , 6, k-k t 2 7 i c-‘(--∎rtsor, A-r" -4-- NO---t O- t-e.,,n
Name(Print) " Mail
. Current in Address.
` i
�
> : (
Signature •--
2,2 Authorized Agent: Steven Silverman
Valley ome Improvemen . , nc. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
.41111 / / Ali"' 584-7522 _ ___-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be l Official Use only
completed by permit applicant
1. Building 5r U[X) (a) Building Permit Fee
2. Electrical JCS. (b) Estimated Total Cost of
I Construction from (6)
3. Plumbing 3 o 1) Building Permit Fee
1 U "
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) (pG) 600 Check Number 3J 1-7/,340 , 0ii4 j 1
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: - --
Building Commissioner/Inspector of Buildings Cate I
File#BP-2014-0078
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE 340 Riverside Dr NORTHAMPTON (413)584-7522
PROPERTY LOCATION 12 DICKINSON ST
MAP 24A PARCEL 090 001 ZONE URA(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 LSI �a 36 3
Typeof Construction: REMODEL KITCHEN,BATH&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
INFO 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
7-;7-,K5
Sigatture 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.
12 DICKINSON ST BP-2014-0078
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-090 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-2014-0078
Project# JS-2014-000158
Est.Cost: $60500.00
Fee: $363.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 4748.04 Owner: BRADBURY DANIEL S&JOHANNA C
Zoning:URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 12 DICKINSON ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:7/24/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN, BATH & 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 7/24/2013 0:00:00 $363.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner