16D-017 (5) l
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d �asartchnsetfs
DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, S VSX/'S/Lr(/r,--In1 r
(licenseelpermiuee}
with a principal place of business/residence at:
�f ��=�- �� �✓�l � , /� z�`,f�.���i i`Z��Z���� (phone#)
(saeei/City/s'a&7io
do hereby certify, under the pains and penalties of perjury, that:
0 T 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 Humber) (Expiration Date)
(attach additiaml shed if necessary to include information pertaining to all oomroetors)
( ) 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 pe aons to eio maintenance,consuuctioa or repair wark on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurt Ant thardo are not generally comidaed to be
emsployen under the worker's oxali=u4on,Act(GL152,ss 1(5)),application by a homeowner fora Grease or pamit may evidence the
lesal ctatua of an employer under the Worker's Compensation Ad
I understand that a copy of this sfatememt may be forwarded to the Department of Industrial Accideats'Offioa of In=ane for the
coverage verification and that fnUwe to secure coverages under section 25A of MOL 152 can lead to the imposition of criminal penalties
comisting of a fl ne of up to$1,500.00 and/or impriso it of up to osx year and civil pe naltia in the form of a Stop Work Order and a
fine of 5100.00 a day agdnst me.
\-)
Signed `day of '` Jy� !/�n ' 7� For depz t xatdl tree only
Permit Number _
./ / ✓/'� i Lot#
sgaahtre of Li ermit#.ee
Office of Consumer Affairs and u��>�ess Reoulation
k 10 P&,-k- Plaza - quite 517
Boston, Massachusetts 02116
Home I[TrprI gene Cq tr4ctor Registration
Registration: 131945
Type: Individual
Expiration: 1011312 14 Tr# 232370
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FQMER RD.
SOUTHAMPTON, MA 0107
Update;address and return card. Bark reason for change.
ddress Renewal al _ Employment Lust Card
DDS-CAI 0 -CA, -Gi0iZ tip
License or registration valid for indivi tul use on iv
Office of 6miumer affairs d 1 iness Regulation
to-
HOME IMF'RC3VEMERETtAll RAGTKIR before the expiration date, if found return eta:
Registration. -131945 Type:
Office of Consumer Affairs and Business 1�i�ulation
�a Expirati�sxt 1 t13f20t4 individuaf
10 Park Plwtaa-'Suite 5170
Boston,'11A 02116
S 1� N A_SILVERMAtN ::.
STEVEN
SILVERMAN
2618 FOMER Fitz.
SOUTHAMPTON,MA 01.073 Undersecretary Not valid without signature
�, 1 t 1
.. :1�.}....:. �Z r
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SECTION 8-CONSTRUCTION SERVICES
License Number
Expiration Date
!r els
Signat re Telephone
9. Registered HgMe.,improvement Contractor: Not Applicabie 0
Steven. silverm n— 131945
Address Expiration Date
Southampton, MA 01073 Telephone 584-7522
S CTION 10-WORKERS' COMPENSATION INSIJRANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be cornpleted and submitted with this application. Failure to provide this afficavit
will result in the denial of the issuance of the building permit.
11. - Home Owner Exemption
The Current exemption lor'humcownmr '' wuxextendcJmiucludc [one(l) or two(2) famUies
and to allow such homeowner toon(yuge an individual for hire who does not poomcoz a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1,
I)efinitionof Homeowner: Person(s)who own a parcel ot'land on which he/she resides or intends to reside,oil which there
is,, or is intended to be. a one or two f`ami1v dwelling,attached or detached structures accessory to such use and?!or farm
structures. A nerson who constructs more than one home in a two-year,peried shal! not be Considered a homeowiler
Such-horricowner"shall submit to the Buildina Official,on a form acceptable tothe BUildina Official,that be/she shall be
responsible for all such work performed under the building perinit.
As acting Construction Superviso your presence on the job site will bc required from hme,ntimc, Juriogondupon
completion` permit is issued.
Also be advised that with refer ucoto6opurl52( Yorkon` Compcnsmioo) and Chapter }53 (Liability ufEnnp!o :mm
Employees for injuries not nnu kin- in J�N u)ofth e Massachusetts Ocxco| Luno Annotated, 6rperso
r(s)
you hire to perform work for you tinder this permit.
The undersigned^'hnmuowoor^coniOco and uonmcoresponsibility for compliance vvi\hthcS�u�c8uUd�n�Codc,Ci��of
-Northampton Ordinances, State and Local Zoning Laws and State of Maomchoscnx General LaysAnnotated.
TIC.N DE SC OF PROPOSE N1pRK (cf rk X61 (1
New Hcu!.e. Aedition L � Replacement Wiadows Xter:rtion( � Roofinf r
Oa Moors .. ,.,
Accessory Bldg. 2 Demohtiw-:1 New Signs Decks Siding E ? Other ' .!
on +cel�
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-w_(_.t'7Ci� tC'6ctl(t`• .._�. .__.....,. I f. .,.1Y",.^k r ;lt i Il.rle,,.r ,.ct_.:".P3ls'1( � [�'w /iAll
sa. If New house and or addition to existing housing. com fete the following.
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SECTION 7a • OWNER AUTHORIZATION -TO BE COMPLETED WEtEW
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERIMT
�+
l�l/A.c/�. [lt� . .1� '..gYW°aCi l":; i:""t s�FEt:?t_ �°ad•�'t'i
S to en ' lverrna;1, val ley._Home._Improvement, . Inc.
1 aEp,! :urn u; IN-
001,14
te�CP_tl '.i�v �.�LZ ey �Qt1nP hiSlg2�Q_VAment.i_InnC..
dcc [r_ _ . . xr• _._rIr`rrr< r, _gin"_ i �I ar --(�,�n rt [Etr f rtr tt .� s EL'-iF,a!_tw�. ,r{� fit,. "t.r i ,E_ ,.r"slr:, kt� !6t ,., �.` Ir'Y
Steven Silve _-__.__.,.._ _.. ___ .....
G .%,
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 ariy proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
Department use only
! ! City of Northampton Status of Permit:
i �l --
-'I Building Department Curb Cut/[r-Ne'way Per
i FEB — 2 204 II 212 Main Street Sewer/Septic Availabiilty
lu Room 100 W S,rl/Well'Availability_ 7w "
Northampton, MA 01060
; TwSets oi` tructural Plans
�c inspections
13-587.1240 Fax 413-587-1272 Plot/Sete P�
Other Spec!fy ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prop ert LAddress: This section to be completed by office
'77 N`4014-1 .NO-tn e, Map Lot Unit
r1o"e'V76-C fla- 0060z' Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�9 �� en c11m O�ta a2��
Name(Pr ) Current Mailing Address:
Telephone
Signature
J
2.2 Authorized Agent: Steven Silverman
Valle Ho a Im rovement P.O. Box 60627, Florence, l 01062
Name(Print) n Current Mailing Address:
584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item 1 Estimated Cost(Dollars)to be Officiai use Oniy
completed by ermit applicant
1. Building t (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing I cv) Building Permit Fee
4, Mechanical(HVAC)
5. l=ire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check Number id 19 i9
This Section For Official Use Only
Building Permit Number: Date Issued: _. _-
Signature:
Building Commissioner/Inspector of Buildings ?ate
File#BP-2014-0838
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 177 NORTH MAIN ST
MAP 16D PARCEL 017 001 ZONE URB(100Z
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR WATER DAMAGE
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
INF9RMATION 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
mo 'tion Dela
Si ature of ildi g 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-2014-0838
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16D-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-0838
Project# JS-2014-001465
Est.Cost: $9000.00
Fee: $55.00 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 O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:21412014 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR WATER DAMAGE
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 2/4/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner