12C-051 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
t _; ®ffice of®19yesfigodoes
600 Washington Street
-.�,;����,;;• Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
r�p�lirant rlFfatnratrbn �' `Plea�,c1'RiId7'l'�l g 77,
�
name:
location:
city Phone
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
PQ I am an employer providing workers' compensation for my employees working on this job.
company name. Valley. Home Improvem6rit, Inc'
address:
3 4 C Riverside Drive
city: , Northampton, MA '0106'0 phone fl: 413-584_7522
insurance co.A. I Mutual Ins `' C0 polievn WMZ8005610 01 <2008
I am a sole LLproprie tor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following wor,:ers' compensation polices:
con]ahv:name:
address:
city' olioner-
insurance co poliev i
company mine:
address:
City,. - rtla n�•a a:•.
u
insurance Co policy#
SrAttttch fldfei�onal sheet if necessan � �` � �.,� .��:�.,..s ... . _,�
Failure to secure covera as required ender Section 25A of 144E>I,152 can!cad to the imposition of criminal penalties of a fine tip to 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 6100.00 a day against me. 1 understand that a
copy of this statement inay be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify unde,the pains afid penalties of perjury that the information prowled above is true and correct,
Sionature— Date
Print name /�� L S' iV j~ _ Phone 4
a+--« �-�-.,°?',°F.•n"- ..... -., t::�` '..ice . � wr'g^T:�?�-' ...F...
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official Ilse onh it)not write in this area to be completed by city or town official
[.'
city or town: _ perriit/liccase P r-Building Department
r Licensing Board
t O check if immediate response is required C]Scicctmen's Outer
01lealth Department t
t§ contact person: phone#; I-1Other
1r,'
Massacbusetts- Department of Public Safetl
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 77279
Restricted to: 00
u
d
STEVEN A SILVERMAN
268 FOMER RD �
SOUTHAMPTON, MA 01073
I
Expiration: 6/21/2010
( mnii.vsiuner Tr#: 25795
T +°omvnwau�ea//� o��i/a�ac✓ZUael�a j
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 131945
Expiration: 10/1312008
Type:
STEVEN A.SILVERMAN
STEVEN SILVERMAN
268 FOMER RD. ��
SOUTHAMPTON,MA 01073 Deputy Administrator
f
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. .
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Steven Si1Lv-erman-.-------,--- 077279
License Nun-iher
268 Fpmer—Road 6/21/10
AddrAess Expiration Date
ignat Telephone
9. Reeistered Home Improve!neqLCqntractor'. Not Applicable 0
Steven Silverm n-- 131945
268 Fomer Road 10113/08
Address Expiration Date
South5a�m _!;o4, MA O� 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 af-ficavit
will result in the denial of the issuance ol the building permit.
11. - .Home Owner Exemption
The current exemption for''homeownos''was extended uoinclude Owner-occupied [one(|) ort*o(2) Families
and mal|nv such homeowner|u en-aac an individual for hire who does not posass u license, provided that the owner acts
as : Person(x)who own u parcel o[|on d m�which ho/sb c resides or intends to reside, o which thu e
is,or is intended to be, a one or two family dwelling.attached or detached structures accessory to such use and/or farm
structures.
Such"horneowner"shall submit to the Building Cill'icial.on a form acceptable to the BUildin" Official,
responsible for all such work performed under the buildiny,permit.
As acting,Construction Suriervisoi your presence on the job site will he required From bmewo time, duringaodupon
completion of tile work for which this permit lnissued.
Also hc advised that with reference on Chapter l52(\Vmrk:n' Compensation) and Chapter \53 (Lia6i|itynf Employers to
Employees for injuries not resulting in Death)ofthe Nluxsuchuse8s General Laws Annotated, you mav be liable k/rpeoun(s)
You hire io perform work for you under this permit.
The undcoiopcd^homoonou/^certifixa and assumes responsibility for compliance with the State Building Code,City o[
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts 6encral Laws Annotated.
HoincownerSignature-
'rQtL-QtL-S- DES CR I VLI,01!OE JL POSELD WORK Ck*�I L.j
N ur w H u.->e 19e�Izu, 11, 1 Window, A!erjtiDn(!,) 1':
tar [3ni7r5
AccEssor y Sldg. -I Dem')1itior,i'' New Signs Decks 1 Siding othe"
Ga. If Now house aiid or addition to existing housing, complete the following;
f" i�l-,z
00 Yt
Y
SECTION 7a • OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as no,c4
Steven Silverman, Valley Home Inprovement, Inc. 0 1
-�Lti" d-*-,f:, vv-, -,trv, '-w, .wd 'h- f;' illy
Steven Silverman.,,
I Niw
c
Section 4. f
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
r
r
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 arty 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:
Building Department Curb:Cut/Driveway P, pit
212 Main Street Sewer/Septic,Availa6ifity
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans .
phone 413-587.1240 Fax 413-587.1272 Plot/Site Plan k
Other Spec `7k
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A'ONE OR TWO"FA1VtILY DW EL`LING
j JUL - 8 2008
SECTION 1-SITE INFORMATION E
This Pr ion
-14 be cortletech o fice
1.1 Property Address:
G C` ''4 d� _ 5�/f 7/lam/ Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
� '� �
2.1 Owner of Record: J /�/ C.-�"
Q-! =,ter �"c � �% A14 C `°Z C 0/ Z-
-Name(Print) Current Mailing Address:
Q .,c,jv�. ,� Telephone
Sign ure
j ?� C) �
2.2 Authorized Agent: Steven Silverman
Valley Home Im roveme P.O. Box 60627, Florence, K& 01062
Name(Print) Current Mailing Address:
584-7522
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
com leted by ermit a licant
1. Building �rL (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) 0 Check Number '.
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
E �' BP-2009-0027
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2009-0027
Project# JS-2009-000038
Est.Cost: $15000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 131945
Lot Size(sq. ft.): 13024.44 Owner: SCHMIDT CHRISTIAN F&KATHRYN
Zoning:URA Applicant: Valley Home Improvement, Inc
AT. 24 CLOVERDALE ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.71812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 7/8/2008 0:00:00 $25.0024376
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo