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....cep:. DEPARTMENT OF BUILDDSZG INSPECTIONS 4 V–=='_—
•. 212 Main Street ' Municipal Building
Northampton, Mass. 01060 'v,
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, s-11!/z/V$I L j/ c.,44/77I, l�'/i,LL,`J //674 z t w sfiterJG%,. c_.
' (licensee/permittee)
with a principal place of business/residence at:
3 y-O ,e//k5 i_b F_. /zi‘'2. ., i- ,z``/7 7d/27J/i raj, ! (phone#) X-f r7$ ?
(street/city/51 atf JZips
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: /
. (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)
(artadt additional shod if necessary 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 while homeowners who employ persons to do maintenance,comuvction'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.Ad(GL152 ss 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worms Compensation Ad.
I understand that a.copy of this staiemmt may be forwarded to the Department of Industrial Aeddeot a 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 fine of up to 51,500.00 and/or imprisonment 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 tun.
Signed 11a'. 1 day of .1' J yi ,f/11/\. 2,0 3 For use only
F Permit Number
i t <./l Y/I; , /r�,, I/: ie4 ✓t i J Map# Lot#
ignature of Li - ermittee
SECTION 8- CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman__ 077279
License Number
268 Former Ro d,_ ..S.► • - 1, • .n, MA 01071 __w.._ 6/21/1+
Address Expiration Date
I
584-7522
Sign ure Telephone
9,iRetitter6c1Horrie Improvement Contractor: Not Applicable ❑
Steven Silverman_-.,-. 131945
Company Name Registration Number
268 Fome r Road 10/131/t _----
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 ih<s application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 3) No
11:. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or twof2) 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
7ETION 5. DESCRiPT1ON OF PROPOSED WORK ( heck miLval.iQ.41.,e)
...._ ,......,..,,... _
New Hcuf.e ...2 Acdition LI 1 Replacement Windows kter.ation(L)X 1 Rooting P
Or Doom
Accessory Bldg. L-1 Demo litio7C New Signs ' I Decks ' I Siding ' 1 Other
fill+CIN;24/) -411 - I n Stql1P ,, ,5-0 8 EWA. 0 JATt,cf_ NiviSe h-Tpi-ce-
.:, „..„. „-,.. ,,, ,-,,... ..;„ ..,:-!-1 o.....,..- :)i-et.nn.--- LA)
1 tiA
i'
.,:a....--1 : Po: \./
sa. If New house and or addition to existing housing,complete the following:
,• I';...i., ::0 ..-.4., h.:.,,-e7 . c-t-, ,Thrn ,.., -7 :, 7 a in,i r C y
' t V.1^-7; •.' -.",* .n....7.r.71°:(',""F ,
c. 1^ `-::,t1 Li. .,:i'!":•:11..::: .:11.7t:,1)E.q7.:.• .,.
:, 1,-.7,. ,; ...!,. : !I :)1'' tlEt'd '!
1
tr.
: r:-- 7.:or-,..7 ia-7: , , , ___ %/1_-_-::: "_., 7:1;:l..zi C...:4Tr,..)1 LN:■.? IF:-)rrn iI:ti_cl (..-c7
1
• ‘,., cr.-0AI„;.1r, *1 w tht ; 1 1. .,:i: .,...K :,,nt,I.„? '-•,' s N1:: I:, r.:.ifistr,,.int. ,..,11 o. ".,!-L :00 ,„.1
t
"!1 :,cq' t,•fAln,,v '1-1e,hlt`C; i:!:1CIS
''. .' 1 nu idri,, .`,:C.:' t;:lrm h..-' :t (.. litlicE14: ;1';'f.. ?:;••.,r-4: t',34:-Iatio'f*,?
• :i.L.1.tie e'lk (7. ',::,. "..;-..-4,-.4,..eq. _ ',..X',y v„ate!
— i
1r SECTION 7a • OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
•k4ofd . as .}.'.rici C :.-E. a.LIL,cct v.:;:-.Att?
Steven Silverman, Valley Home Improvement, Inc.
rr, 12,-....-Hr E ' 0 1 -I.-'tt", ',.t. ..71.,:t.- if w.,',1-, -1:1!tr-wt-i., :v., Pit.. ',..;-. :: tre: .t..,1- 1: :1:11:IK,-AP. f
— _12,3f13
-• — _ _ _________ ____
coo a:Jr?Ix u...3.1
■
. stemen_ stiverraan, Valley Home improvement„,—Inc,_ , .-t,„ : ".',v-r fAlit-ffl :71-1 1-4:1-f:1 !
!V.".•.±,,' dt.:.(2'?lc ".-El: ..f.v2 Itaketnt.r.:, ?ft(' tr,Pvr-L':,!.:411..r. OW rs',r':1,1':-W ii":'oi.:4(*--1 t 1c,• -1,1 "1.1-,1 ,imi i-if:,,.:r'Itt, P,, 'Ilt! L”-•.: /.' IrY
.,?c re E...nr bclict".
I _
.7..47-C2 --C.,;:' :1-: -,j'i!-,v 'i, e`'...1 r.''..-,o '..t,.:1, u i-:'-',1- ".
Steven Silve oan___ 'I
*
1 i dir- /1, 9/2_3 /3
7. 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 j
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 i' 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:
Department use only
City f Northampton Status of Permit:
2 4 2013 g n De artment Curb Cut/Irl ewa Permit
SEP g p y permit
21 Main Street Sewer/Septic Availafiifity
Electric,Plumbing&Gas G lnsr--coons oom 100 Availabilit y
Northampton,MA
Northampton, MA 01060 TWO/Sets of tr. ctural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site
Other
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
J ( i -ect- oiGi t 'e k Map Lot Unit
Of-eX- 'C a`0 2`- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
V {lltj fi l a 1"' i 5/ pct &I- nocerzc c /2&I 6 6 z
Name(P t) / Current Mailing gti�r ss: C7 Sibs"
Telephone
igna
2.2 Authorized Agent: Steven Silverman
Valley Home Improvemen , Inc. P.O. Box 60627, Florence, MA 01062
Name(Print Current Mailing Address:
584-7522
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building p (a) Building Permit Fee
1
2. Electrical i r (b) Estimated Total Cost of
1 j t Construction from(6)
3. Plumbing ()/\ Building Permit Fee
4. Mechanical (HVAC) �I J
5. Fire Protection ii (� /1/6
6. Total = (1 + 2 + 3 + 4 + 5) 1 11 Check Number
This Section For Official Use Only
- Building Permit Number: Date Issued: �.
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0370
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 57 REDFORD DR
MAP 36 PARCEL 054 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /16 9 All 7
Fee Paid
Typeof Construction: REMODEL KITCHEN&REPLACE WINDOW W/SLIDER
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 TION 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 • De .
/9-67--/Y
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.
57 REDFORD DR BP-2014-0370
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-054 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-2014-0370
Project# JS-2014-000619
Est.Cost: $19600.00
Fee: $117.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq.ft.): 12501.72 Owner: BARRY PAUL
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 57 REDFORD DR
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:9/24/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & REPLACE WINDOW
W/SLIDER
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 9/24/2013 0:00:00 $117.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner