35-295 (4) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ollovestigatioos
600 Washington Street
w y ,ter Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name,
t
location:
city
Phone'
I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
fXJ I am an employer providing workers' compensation for my employees working on this job
company name: Valley Home Improvement, Inc .
address: 340 Riverside Drive
city: Northampton. MA 01050 nhoneg: 413-584-7522
insurance co. Acadia Insurance Co. policy WCA 0109302-12.
-— __ -
_ -, TAMM M M71,
M� v
1 am a sole proprietor,general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the foilowM2 workers' compensation polices:
company name:
address:
city: nIt one=:
insurance co. policy
company name:
address:
city: phone 9:
insurance co Policy#
� Ek4ditroA`a fh-ieti netesf'- 'sa°-
Failure to secure coverage as required under Section 25A of NtGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coveraze verification.
1 do hereby certif✓under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
,( 3 L , �7
Print name / /��% /� ���� r' ' Phone r /7
official use only do not write in this area to be completed by city or town official
�. t:
cit} or town: p ermiUlicense OBuildin Department
r. ❑Licensing Board
❑check if immediate response is required ❑
Selectmen's Office
❑Health Department
contact person: phone 9; 00ther
(,-,-d 3+95 P1.A)
y
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 077279
Bi rthdate: 06121/1964
Expires: 06/21/2008 Tr. no: 24270
Restricted: 00
STEVEN A SILVERMAN
268✓=OMER RD e�
SOUTHAMPTON. MA 01073
Commissioner
i
.Tte !^arxrrearuue<ziC�z cf� Gla�;trc',itueCtl
y Board of Building Kegalations and Standards
�rn
HOME IMPROVEMENT CONTRACTOR
75 y Registration: 131J45
Expiration: 10/13/2006
Type: Individual
STEVEN A. SILVERMAN
STEVEN SILVERMAN
73 WHITE ROCK RD.
YARMOUTH, MA 02675 administrator
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Steven Silverman 077279
License Number
73 White Rock Roa Yarmouth, MA 02675 6/21/0'
Address Expiration Date
584-7522
SignatTire Telephone i
9 Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Comgany Name Registration Number
73 White Rock Road, Ya quth, MA 02675 10/13/0
Address Expiration Date
J/7,1-1—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 buiiding permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. 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. CM'Z 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-vear 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
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemen Windows Alteration(s) ❑ Roofing ❑
j Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] O/ther.[t ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 7 Renovating unfinished basement Yes No
Plans Attached Roll - Sheet i_
6a. If New house and "or addition to existing housing complete the followih.
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stcries?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
P-Taq, UZOI)AIJ , as Owner of the subject property
hereby authorize Shaven Silverman Valley Home Imnrovement Tnr_ ___to act on
my behalf, in all matters rejative to work authorized by this building permit appli7n.
,i G
Signature of Owne Date
I, Steven Silver as Owner/Authorized Agent
hereby declare that the statements and in ormation on the foregoing app ication are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Steven Silverman
Pint Name
v
. ,Department�s�e`only ��,�
City of Northampton Statu��CPerm�t.
Building Department Curb Cut/Drve�iy Permit '
r 212 Main Street Sewer/Sept> allabil.it
Room 100 Water/Wel(Availabili
Northampton, MA 01060 Two Sets of Structural Plans �� ��� .r
phone 413 587.1240 Fax 413.587-1272 Plot/Sitsans .a .. .
ether Specs �k �. .
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
�35 W OODLANO ROAD Map Lot Unit
FL 2 f(-E0 C G MA V l V G Z Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) /z Current Mailing Adds: -1- Ys„
Telephone yy
r
Signature
2.2 Authorized Agent: I
Steven Silvqjrman h P.O. Box 60627, Fjorencp , MA ni nti2 f
Name(Print) Current Mailing Address:
413-584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building f Poo d. (a) Building Permit Fee
2. Electrical (b) 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) o Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
;ign atu re:
Building Commissioner/Inspector of Buildings Date
85 WOODLAND DR BP-2007-0469
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-295 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0469
Project# JS-2007-000690
Est.Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 131945
Lot Size(sq. ft.): 38942.64 Owner: JORDAN PETER A&SUSAN J
Zoning: SR Applicant: Valley Home Improvement, Inc
AT. 85 WOODLAND DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.1012512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT ENTRY DOOR
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 10/25/2006 0:00:00 $25.0021713
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo