16D-017 (6) as a : W erg
-
CS-077279
268 Fortier Road
Sowtltampton MA-1110
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Office of Consumer Affairs and Business Regulation
�. . 10 Park Plaza Suite 5170
Boston, Massachusetts 021 1
1lorne Improvement Contractor- Registration
Regis€ration: 105543
Type: Private Corporation
Expiration: 711712016 Tr# 2W29
VALLEY HOME IMPROVEMENT INC.
STEVEN SILVERMAN
P.O. Box 60627
FLORENCE, MA 01062
V plate Addreai and return caret. Ma rk reason for chance.
.Address Renewal F:rnp40yruaent Lost Card
4 Inv c,crinmurfwCuccrc tff 111USN"Criusu@6s
,. � .. Department of Industrial Accidents
,Z
Office of Inv strgations
6100 Washington Street
Boston, lilA 02111
-` www.mass.gov/dia
11'arkers' Compensation Insurance Affidavit: Builders/Co tract€Irs Eleetricians/Plumbers
ARPlicant Information Please Print Legibly
Name (Business/Organization/Individual): G
Address:
City/State/Zip: 1�f��� �_ C)�'i e#:
Are you an employer? Check the appropriate box: Type of project(required):
1.CA I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).
* have hired the sub-contractors 6. E] New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition.
[No workers' comp. insurance comp.insurance.1
i v.n uiecun_ai re'-aia'�vi'auui`eivli5
required.] 5• ❑ We are a corporation and its u � o
3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 131-1 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 and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: OQCJ G S Expiration Date: t I
Job Site Address: 19 I N0r�2 City/State/Zip: RVence owl- --
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify the pains a rd penalti;. perjury that the information provided above is true and correct
Si ature: Date: J
r
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
City Oifylorthainpton 212 Main Street, Northampton, Na 01060
Solid Waste Disposal A-ffda-vit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition dition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined.by MGL c I 11 , S 150A.
Address of the work: HOIn
The debris will be transported by:
The debris will be received by: a4
U
Building permit number:
Name of Permit Applicant �QALW
pate Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
ktName of License Holder: '3 (\ 1,
License Number
r -
Address Expiration Date
zVz/,46 --- `l
Signatute elephone
9.Registered Home Improvement Contractor: Not Applicable ❑
�n 1�1`),��rlCQ r--� /0,55 V 3
Company Name Registration Number
to o . ?-va 6 ,- , io
d -7 /11 / //4
Address Expiration Date
()\D�rZ 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 EgemiDtion
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.Clot 750, 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 ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [E] Siding[p] Other 16
Brief Description of Proposed {{}} y G ` S l d/
Work: 'R byL'I c;-E TNSLtLAT)0J �7 V� tynii ClLl z by d '
'SR) Y n,p
Alteration of existing bedroom Yes No Adding new bedroom Yes _ ?--� No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if New house and or addition to existing housing complete the following:
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 .
1. 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
I, (�Z L�� �l/��� t'� ,as Owner of the subject
property
hereby authorize G�'E�v S/ � � �14tj
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
YT t-UEN
Print Name
Signature of Owner Dare
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 Pennit/Variance/Finding ever bee issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body o water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or ne d to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the pr petty? YES 0 NO
IF YES, describe size, t pe and location:
D. Are there any propose changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe ze, type and location:
E. Will the constructiod n activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
ity of Northampton Status of Permit:
-- ullding Department Curb Cut/Driveway Permit
i l 212 Main Street Sewer/Septic Availability
AUG 13 215 Room 100
Water/Well Availability
No hampton, MA 01060 Two Sets of Structural Plans
Elect Up �V4 87-1240 Fax 413-587-1272 Plot/Site Plans A
NcrthairP4on, VA 01060
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
1 n ' �.�
t q q No/� HOU4 ! S7L Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
IId 54 &1moqk- "a CaLI'7y
N me(Pri t) Q,, Current Mailing Address:
, D T'-nq SJ—� Telephone �,�—��^ ���
Signature
2.2 Authorized A ent:
S P Z)2=-c (00(n2q a d► 2
Name(Print) Current Mailing Address:
;0/7 1)` �ffl / 'A 13-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 56 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(Hk/AC)
5. Fire Protection
6. Total=0 +2+3+4+5) 57,0 6, Check Number b
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissionerlinspector of Buildings Date
File#BP-2016-0182
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 177 NORTH MAIN ST
MAP 16D PARCEL 017 001 ZONE URB000)/
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: REPLACE INSULATION &DRYWALL IN SUNROOM
New Construction
Non Structural interior renovations
Addition to Existing -
AccessoryStructure
Building Plans Included:
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved 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
atureof Date
Not e: 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.
177 NORTH MAIN ST BP-2016-0182
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16D-017 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-2016-0182
Project# JS-2016-000310
Est. Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 18295.20 Owner: JACKENDOFF RAYMOND&HILDY DVORAK
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 177 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.811412015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE INSULATION & DRYWALL IN
SUNROOM
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 8/14/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner