22B-038 (4) y
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
//5/Ll/'�c �/riG�
(IicenseeJpermittee)
with a principal place of business/residence at:
11t714 (phone#) ���SZl
(strcct/city!s',a&rip5
do hereby certify, under the pains and penalties of pedury, that:
0 I 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 Compairy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiomi sheet ifneo=uy to inrh information pertaining to all oomracton)
( ) I am a sale proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE-please be awwo that while hoc=woeta who employ persons to do au steam ce,con&uction or fair work on a dwelling of
not more than tl sea units is which the hon=wntr r=dw or m the you ds"u wnw t thereto am not Soxmlly ooamle ed to be
employ=undrr the wok tt's. atics Act((i1 I52�s 1 C5)7.application hY a homeowac for a liceu�e or permit may evidence the
legal stahss of an employer under the Workee's C.ompamatioa Act.
I uaderstaad data copy of this zw mmt may be lorw a ded to the DeqWw=ent of Industrial Ac=id:&ofoa of insxusow for the
coverage vcxifi=oa and that failure to S==coverage I section 25A of MGL 152 can lead to the itxpcssui on of criminal penalties
comisting of a$ne of up to$1,500.00 andlor of up to onr yrar and civil penalties in the form of a Stop Wort order and a
fine of 3104.00 a day against me
Signed _day of For degar000=al use only
/ Permit Number
Ivfap# Lot#
iSnature of Lict ee
SECTION 8- CONSTRUCTION SERVICES
Narne of License Holder : Stevez__Si2_v_e=an___.__ 077279
268 F 6/21/1
�d ss Expiration Date
Signature" Telep�cne
i_ 131945
Company Name Registration Number.
Address Expiration Date
South��m 584-7522
�tton, MA 01073 Te�ejDhone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with th's appHication. Failure to provide 4his affir.awt
will result in the denial of the issuance of the buhding permit.
11. - Home Owner Exemi3tion
The current exemption for^houeo*ncr ^ was extended mioc|ude Owner-occupied [one(l) or ^,u(2) famUiea
and m allow such homeowner/ucn�o�cnnindividual kx hire who does not poum�sulicense, provided that the ov,,ner acts
Homeowner:as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Person(y)who own pucd o[|aodouwhioh hc/vhcreuidescx intends to reside,on rvhixb there
is, or is intended to be, a one or two family dwelling,attached oi-detached,,tructures accessory to such use and/or fiar.,11
structures. A person who constructs more than one home in a two-veir wriod shall not be considered a hoincowner.
Such "horneown.-r", shall submit to the Building Official,on a forin acceptable to the Building Official,that he/sheshall be
responsible for all such work, performed under the buildin perinit.
As actim,Construction Superviso your presence on the job site will be required from tirne to time,during and tf-on
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) arid Chapter \�� (Liability of Emp|nycnto
Cmployeles6/r injuries not resulting in Death)of the Massachusetts General Laws Annotated, 6*rpcoon(u
you hire io perform work for you Linder this permit.
The undersi-ned "homeowner"certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, 8mtc and Loci] Zonioo (-ovy nod Sr'Mv n[K4assuchuse-ns Gcoxml Lx"'s Annotated.
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AccESac?."y Bleg. DE;ditic- NEVI' igr'= Yt'E'
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6i,. If New house and or addition to existing housing, complete the following.
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SECTION 7xa w OWNER AUTHORIZAT*N . TO BE COMPLETED WHE14
OaP 14ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t iST1 V /0
.._ / ! as tee';« ste E ! _Atir
Steven_ Silverman, Valley_Home _Improvement, Inc.
..% e -en—.�-erma n $�..Z.iy!Hf�lffi£ I�lj �?1�@]YLe1�t � IiC,..._ r f�iW .`t'1 c.'1 '.C,0-t:t
1�_�, _►r'� ' _.. _•`�Et'tCt� e_a dlr. lri qr jjw r ;,j itra tier ° C° 'wtlr 1;r ;per
I
Steven Silve
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:
t'
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/Findi/rb ued for/on the site?
NO DON'T KNOW
IF YES, date issued:
IF YES: Was the permit recorded at the ReNO DON'T KNOW
IF YES: e nter B/k, Page and/or Document #
B. Does the site conta water or wetlands? NO DON'T KNOW
YES
IF YES, has a peo be obtained from the Conservation Commission?
Needs to be obtbtained Date Issued:
C. Do any signs exist 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 of Northampton Status of Permit:
WW ��o� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailabi6ty
Room 100 Water/Well Availability
Northampton, MA 01060 Twa Sets of Structural Plans . .
.�> phone 413-587-1240 Fax 413.587.1272 Plot/Site 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
37 Map Lot Unit
Zone Overlay District
Elm St. District, ___ CB District _
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr in Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Vallev Home Im roveme Tno 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 ermit a olicant i
1. Building 2/ tIt/ (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing �� Building Permit Fee
4. Mechanical (HVAC)
5. 'sire Proiection
6. Total = (1 + 2 + 3 + 4 + 5) z 3 y Check Number
This Section For Official Use Only
i
Building Permit Number: Date Issued: __ —
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1025
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 26 CORTICELLI ST
MAP 22B PARCEL 038 001 ZONE URB(100)[WP(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
Typeof Construction: ENLARGE 2 KITCHEN WINDOWS&REPLACE WATER DAMAGE FLOORING&
CABINETS
New Construction
Non Structural interior renovations A
Addition to Existin4
Accesso1y Structure C
Building Plans Included:
Owner/Statement or License 077279 /r
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON �/a
INFON 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
Demolition Delay
Signature of uildmg RfficiaT 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.
26 CORTICELLI ST BP-2014-1025
GIs#: I COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22B-038 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-2014-1025
Project# JS-2014-001776
Est.Cost: $23400.00
Fee: $140.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 11020.68 Owner: GREER CHRISTINA
Zoning URB(100)/WP(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 26 CORTICELLI ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:41812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENLARGE 2 KITCHEN WINDOWS & REPLACE
WATER DAMAGE FLOORING & CABINETS- windows must be energy star w/appropirate headers
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 4/8/2014 0:00:00 $140.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner