24A-142 •
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`�W'- DEPARTMENT OP BUILDING INSPECTIONS _
212 Main Street • Municipal Building
Northampton, Mass. 01060 ow'V�
WORKER'S COMPENSATION ] SURA.NCE AFFIDAVIT
L 57-- le/V 5/L1/40/M J k /12.1-1-1 /14OMf ✓� 1 i�lzc//iAre16...
(licensee/permittee)
with a principal place of business/residence at:
3Y-0 , //' 'L i_ j- .�i i'Z ,/2(:/ ;7 = Z/t, 14 (phone#) X 7 2_
/ (str et/city/si;temps
do hereby certify, under the pains and penalties of perjury, that:
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)
(attach additicaal sheet if necessary to.iarlu§e infix-motion pertaining to all mss)
( ) 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 pawns to do msir,tea=un,coastruetion or repair work on a dwelling of
not more than three units in with the homeowner resides or on the gonads appurtenant tbec o are not generaLly considered to be
employers under the worker's oemp =dim Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal statue of an employer under the Worker's Compensation Act
I understand that a copy of this determent may be forwarded to the Department of Industrial Accidents'Office 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$1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Wodt order and a
firm of 5100.00 a day against me.
I
Signed1ls 1 �d^ay of '� J'��1,,%11 y\ 2,0 For departm�l use only
j / Permit Number
Ar ,/IJ7%; , l i 4,1�//V4' 9 Map# ,Lot#
d..
ignature of Licenseef1�ermii tee
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman.-_ 077279
License Number
268 Fomer Road, 1. • - 14 • ., ,_..._MA 01073 ___.-__._.__ 6/21/114'
Address Expiration Date
i
_ _. 1i A Jill l _584-7522__._-__
Signature Telephone
9. Registered-Home improvement Contractor: • Not Applicable ❑ H
Steven_$ilverman_-_ 131945
_.._
Corn an Name u__---
p � Registration Number
268 Fomer Road 10/13//14
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 X 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 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 155 (Liability of Empioycrs to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable?car person(s)
you hire to perform work for you under this perrnit.
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
'7,31c-r!ON 5. OEScRIPTION or PROPOSED WORK (check All wc.,Ihje)
NUVs' t-tcust.: L...: ' ALdition ,_.1 i Replackineht Wiedows , kteistitm(N)71->, 1 Roof int:
Or Doors :: I
Accessory Bidg. Dentolitio;%_i New Signs I Decks 1 ] Siding I Other
_.,1,,kfliP4 C...: _ b T\.--1 Fccro,a, p f■ )f\% C-- -t LI 14.
- 4 1
— • d
.., -,,,,,,, .,.t -).1,..*.st:.: ::,t.:'.: :-:.-i _ Y.---`., _ _ , Nr•, ;I* '.1 1,R 0:•1'‘,L .tiI:HT:r...-- --, _______
•.t.. [e,.: No-rAt'.': " ..-.7* .riot. ii .,11' °M..ht....) :,,ti.;11.1,:fr 't
If New house and or addition to existinl housin., complete the followingj. 1
:-A ...0 Ic..:;'.c C-ft= 7arn Tv..,.::
t^• S '1 F.:71,7):1 ",;t"': ‘, ti r.t. \fr''''!":'..=7.' f,t n.:iti','(1,7;`":":., ■
1
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'4*, LI l'Ai.'7,1..2 yi "1,„:.: .)1,-Ilt _ • __.,°( ,
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SECTION 7a . OWNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES OR BUILDING PERMIT
ant- eAr 1-acid , ...-„, -:,....„:„ ,. ...-, i.JL.,/...c...1 r.,--..',......,...ity
Steven Silverman, Valley Home Improvement, Inc.
r 1..'1 v.t■r.... .-!ttttlt -wt;-,t.; "d!, Prif,, L":„A :'.: ni: •+E7'
.
C Ur;V:f „,:ltr:'
. ,Stemen.....Siimenitans_Valiey_Home_Inproxemen.t..____Inc, , ,-. . -...:.i:1,./., ;).. ::;, ;,,,,--1
',-K :-.-try 1,2c-:r 7-17,7. ..-tL" '.;:-Att:111C-r:, t;titt..tt rit.74:— .t.'t...,It fj-, the i: it'..q.,1 :,,itiQ* i." tt g
rc... ,-..cr.:(7. 7nr.-:
Steven Silverm. ....„______ i _ _
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This cgYumn to be filled in by
Builds ig 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/Fipiding ever been issued for/on the site?
NO DON'T KNOW I/ YES
IF YES, date issued:
IF YES: Was the permit recorde• at the Registry of Deeds?
NO DON'T NOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contai a brook, body of water or wetlands? NO DON'T KNOW
YES ,
r
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:
i Department use only
ity of Northampton Status of Pe't:Mit:
i uilding Department Curb Cut/Driveway,permit '
j Li. Nuv 2 0 2013 212 Main Street Sewer/Septic Availability ,
Li Room 100 W4t'er/Well Availability ;-�
___. :.
Eieciric P Wmn n��;c <�to<;, t,�,�l,+rthampton, MA 01060 Two Sets of Structural Plans t,
No,thu.r,picn, l,,.::c.! . �� ', :
587.1240 Fax 413-587-1272 P1otlStte PI
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
39 R'coe 1-1--Lc nu-e- Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Narhe(Print) Current Mailing Address:
Telephone
Si nature
2.2 Authorized Agent: Steven Silverman
Valle .me Im•rvemes , I P.O. Box 60627, Florence, MA 01062
Name(Print) I / /' Current Mailing Address:
/�it�If
j / 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Ruiiding a C��) (a) Building Permit Fee
,
2. Electrical __ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing J U0 Building Permit Fee 1
4. Mechanical (HVAC)
5. Fire Protection n $56 6. Total =(1 + 2 + 3 + 4 + 5) 1 •).(5�.) Check Number 3)" ,d
This Section For Official Use Only J`
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0640
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 39 ROE AVE
MAP 24A PARCEL 142 001 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 /6 c6c
Fee Paid
Typeof Construction: REPLACE BATH FLOOR
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
INFORMATION 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
_ o ' ion Delay
4Orr. /—*/2
Signa re o uilding 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.
39 ROE AVE BP-2014-0640
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 142 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-2014-0640
Project# JS-2014-001089
Est. Cost: $2200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 8015.04 Owner: LADD JENNIFER
Zoning:URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 39 ROE AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:11/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE BATH FLOOR
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 11/21/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner