23D-018 (4) � * �assxchnseffs
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ° Municipal Building '
Northampton, Mass. 01060
WOPM ER'S COMPENSATION INSURANCE AFFIDAVIT
' (iicenserJpermittee}
with a principal place of business/residence at:
�"TIZ 1,-114 (phone#)
(Str�f/Clfy/S' fP%1D
do hereby certify, under the pains and penalties of pedury, that:
0 T am an employer providing the following worker's compensation coverage for my
employees working on this job:
/kAi/-f LS'�f G� b110 021`l_I%- z 1 Ors
(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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lmn-ance Company/Policy Number) (E°piration Date)
(Dame of Contractor) (Insurance Company/Policy Number) - (Expiration Date)
(atlas additional shed ifner4 s to 4 h,da iaform8aon patiiaing to all cooractocs)
( ) I am a sole proprietor and have no one working for me.
( } I am a.home a Winer performing all'the work myse`f
NOTE:please be aware that wltila homoowmm who employ p=ons to do.II1 ( mAM� cdon-or mair wark ou a dwelling of
OX mom them t =jL,-is.?�a^h t!-- tL-- air•so to€--
°w.il��••ZJk �" C.-+.... w i�.f�ti:T��`�i„��(,�. � f,?1+`�.,sd✓u bl` m uu-= .ws...1J '4 uvwmL.`�Ji��Fi m L�}'�wl'i�3=�:1�v Iry
legal statue of an amployer underthe Wei': s C=p=satioa AcL
I wild X14=4 tip A.OcPy of Cais sic3c =—y bo fo watdr,1 io tb,6 Dep~rb=�_of Yadustial Accid=ts dfoa of FnzUm=fa:the
covesrge vaific:dim and that fadure to se aero covcmco lm sectioa 25A ofMOL.152 am lead to the imposidoa of caimhul penalties
cow of a_fi2c of up to$1,500.00 anNor imXL-�of up to our yew and civ`d praatdes is the fa-m of a Stop WorL order and a
Sao of 5100.00 a fty agdnl rte, {rte_(I
Slgne�l `day Of 1 FW& �user caly
Permit Number
Ti—of L;,; 'prrm f
't
. .
! SEC C 01��TR�CTU�& SEBV{CES
Karne of License Holder: Steven--ZLilme an--- 077279
LrM
268 FF er Road. - ptan.,-.MA 01Q71 6/21/14o
dd
9.ReLyistered Home improvement Contractor: No:Appkcabie 0
Steven SilveMan 131945
268 Fomer Road
Southampton, MA 01073 -Te.;ephone-584-7522 —
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §255-C(6))
Workers Compensation Insurance affidavit must be completed and su�mitted with th�Ls appl'=ticn. Failure to provide 'his aff'idav't
will result in the denial of the issuance ol the building perrn�t,
I I.,- Home Owner Exemption
The current exemption for`hou-ienvm/ors` *as extended minclude Owner-occupied [mo:(}) or twc(2) families
and to allow Such bomennnrr/oonaoaeuo individual for hire who does not possess license, provided that the owner 2cts
Homeowner:as suven--iso.r.C.NlR 7SO. Sixth Edition Section 108.3.5.1.
Definition of Person (s)who own pmzJ of land ou�bich hcihcr-Isidrs or hntcod&toreside, on n6jcbihcre
iu. oris -Inxcndodzcbc` uooeorn,o [bnnilydn.eDi»a.uoadhrdmrdrrochrdSm.rmrenmcucsm`rvmwmha^nuud/orfhnn
s�oc1u;-es.
Suuh'^bomcnnnor'sbuUouboi\totbeBuUdingO85ciuLonafxmocccptah}otothcBu3diogUfficiu|
responsible for all such work performed under ffic buiidin2 permit.
As ucdoo }nur nlrsonc*on rbojoh.i|o will he re9vireJ from time to dmc'during and upon
completion nf the work- for which thi`pcooitixissued.
Also hc advised that with reference ro Chapter l52(Workers' Compe-ouc/ion) and Chapter lj� (iiabi|byufEmpfoy:n/u
2rnp|oy�-,,�s for injur-Jcy not rcsuhin-io [)cu;b)of the Vluou:hus--ttsGoncru| Laws'4nootgrJ. YOu may he Iiahle 6urperson(s)
you�,�ro
to perfbon n'ork /c)ryou under this pcnnh,
The undersi2ned"honico\vner"certifies and assurnes MSPOnSibility for compliance with the State Buildino C'ade, i7 of
cncrol L:rpx Asno/zucd
II:muor,mcr Sic-ne�src _ _ _________
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. 11 laic"4w' frzouse ztW or additier, to exist-mg housing. compic^te hg— follo%yir : �
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SECT€CN a - OWNER A!!TNCPNZATI ON TO SE CQtirPLECCD WHE 13
i OWNERS AGENT OR CON T i>*ACTCR A=PLf E- FOR BLILDING PCP111IT
f
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of r .' eEt @Tl Silverman s27 u 1 Hf?me Inp'rdvGffi°1"$t• Inc. ,
will
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Steven Silverm-
ALL ENTFORMATIGN MUST BE COMPLETED, or PEA T CST BE
DENUD 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 iss ed for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of eeds?
NO DON'T KNOW YES
IF YES: enter Book age and/or Document#
B. Does the site contain a brook, body of ater or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or ne d to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the pro erty? YES NO
IF YES, describe size, ty. e and location:
D. Are there any pr posed changes to or additions of signs intended for the property?YES _
N.U
IF YES, describe size, type and location:
Department use or.�y _..._._._--
City of Northampton Status o"Permit:
CE C C, Building Department Curb Cu/Driveway Perm,it
212 Main Street Sewer/Se ticAvailabiiit
MAY 3 0 2014 -}� Room 100 Water/Well Availability y
ii rthampton, MA 01060 Two Sets of Structural Plans
Olae141 -587.1240 Fax 413.587.1272 Plot/Site Pfahs
Electric, Plumbing 8 as Inspections
Ncrth�,mpton, MA 01060 Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY Dk rELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
SLko Map Lot Unit
Zone Overlay District
Elm St. District CS District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r LY v-� 54O Elm. S� r� Ra 6l 0
:ignature
e�' t) Current Mailing Address:
58Vf 6,5v2 Telephone
2.2 Authorized Agent: Steven S lverman# A),valle nom-e Ira okra T-nr, P.Q. Box 60627, Florence, NIA 0106?
Name(Print) Current mailing Address:
�, 56.4-7522
Signature Telephone
SECTICNI 3 - ESTI!MIAT'ED CONSTRUCTION COSTS
i .tam EstimaeG Cost(Dollars) tc be uiiciai use Only j
completed by ermit applicant
1. Building �1 1 � rf� (a) Building Permit Fee
2. Electrical G� l (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
on
6. Total =(I + 2 + 3 + 4 + 5) � ) Check Number 6 3
Ibis SecttGn Cllr Official Use Cniy
i
I Building Permit Number: Date issued:
Sign t —
s
i Bu !ding Commissioner/Inspector of Builcings L ate
540 ELM ST BP-2014-1276
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:23D-018 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-1276
Project# JS-2014-002141
Est.Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 7100.28 Owner: MCKEEVER CHRISTOPHER J
Zoning.URB(100)/WP(30)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 540 ELM ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.513012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-RE-ROOF REAR MAIN HOUSE
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 5/30/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner