36-274 (5) The Common,weallh of Maassachuasetts
- Depaat nerut of Indm,tfiad Acci'ents
J r
Office of Invest gatioAs
' = 600 Washington Street
Boston,AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name usiness/Or anization/Individual ' / ° �l % j'�.G 1//I%�fC!?l✓� Ll J -
Address: t1 Ye, k�
c�)O 6 U Phone#: 3 " 7S 2—
Are you an employer?Check the appropriate box: Type of project(required):
1. X. I am a employer with J 4. F1 I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. Demolition
working or me in an capacity. employees and have workers'
g Y P tY• $ 9. ❑Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy aged job site
information. _
Insurance Company Name: &llr'/1
Policy#or Self-ins.Lic.#: �,L��3� ��Z 1 L' Expiration Date: _/Z//
Job Site Address: 10d tC City/State/Zip: T�U8 c.0 kcc Ol O LO2L
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi gations of the DIA for insurance coverage verification.
I do hereby c ins and enalties r TFIZI" that the information provided above is Ime and correct.
Si afore: r� Date:
� 2l
Phone#
Official use only. Do not write in this area,to be completed by city or town officiad
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of]Health 2.Building Department 3. City/ll own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone u:
Dep sri
t re r Sitsrrman
�aatlaataaptaaca l pki�' .�� .
-4 Office of"ConSUMer Affairs and Business Regulation
10 Perk Plaza - Suite 5 176
Boston, %'1`,1SSclChUSettS 02116
Monte Improvement Contractor Registration
Req strat on: 1 05543
Type: Private Corporation
Expiratfcan: 7/17/2016 Tr# 254029
VALLEY HOME IMPROVEMENT INC.
STEVEN SILVERMAN
P.O. Box 60627
FLORENCE, MA 01062
Update Address and return card.Hark reason for change.
Address Renewal Lruployment l.wst Card
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holdere (\
License Number
(a
Address Expiration Date
Signat a Telephone
9.Registered Home Im rovement Contractor: Not Applicable ❑
Company Name Registration Number
jcc�m�r w \3� \y
Address Expiration Date
6\0 Telephone���
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....... , 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.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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[p] Other[a
Brief Description of Proposed �, ' I
Work: /`` /r31'P� //C'U1(►'Y` — A 4
�
Alteration of existing bedroom Yes_ X No Adding new bedroom Yes ? No
Attached Narrative Renovating unfinished basement Yes ND
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing, complete the followinq
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 stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. 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
as Owner of the subject
property
hereby authorize I/
to act on my behalf, in all matters relative to work ' horized�y this uilding permit appli ation.
1'7 1
ignature of Owner Date
I, as Owner/Authorized
Agent hereby declare that the statemen s an4J information on khe foregoing applicati n are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name Z&
JOR)
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 be issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Reg" try of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body water or.wetlands? NO 0 DONT KNOW (D YES 0
IF YES, has a permit been or ne d to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the pr perty7 YES 0 NO 0
IF YES, describe size, t e and location:
D. Are there any propose changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe s' e, type and location:
E. Will the constructi activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb o er 1 acre? YES O NO Q
IF YES,then Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Q �/ P This section to be completed by office
loo O 44tr e16I if— IBC Map Lot Unit
`vl Z Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0v- at c.1 tcb a 6/ b�
Nam (P' t) � -� g`' Current Mailing ddres
Telephone �
gnature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
aA- *3 - 7yq 9,S
2Z
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building j (a)Building Permit Fee
2. Electrical l^�(,p (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) Check Number 6
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
100 MAPLE RIDGE RD BP-2015-0339
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 36-274 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-2015-0339
Project# JS-2015-000623
Est. Cost: $12960.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 41382.00 Owner: PAGE MATTHEW&SARA ROSE PAGE
Zoniny: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 100 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.912212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 9/22/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner