30C-054 (6) 528 FLORENCE RD BP-2016-1222
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C-054 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-2016-1222
Project# JS-2016-002105
Est. Cost: $3000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 45607.32 Owner: DAY ROBERT A&ANNE M
Zoning'.SR(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 528 FLORENCE RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.•4/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE SOUTH SIDE OF GARAGE
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 4/19/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
t�
_ II 212 Main Street Sewer/Septic Availability
APR ( Q 2016 { Room 100 WaterMell Availability,
i
N rthampton, MA 01060 Two Sets of Structural Plans
aEr r c r 41 4-557-1240 Fax 413-587-1272 Plot/Site Plans
r=cr;rr --- 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 - -
Map Lot Unit
DNDb2
Zone Overlay District
Elm St.district CB District
SECTION 2-PROPERTY OWNERSHIPfAUTHORGZED AGENT
2.1 Owner of Record:
+ Nay- law �Vneilcq-
Na (Print} Current Mailing Address: � �
Telephone
Signa@ re
2.2 Authorized A t:
Name(Print) Current Mailing Address:
Signature V P7771 Telephone
r
SECTION a-ESTIMATED CONSTRUCTI016! COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �1py � (a)Building Permit Fee
2. Electrical I ✓�•l.t� (b)Estimated Total Cost of
i Constriction from ,
1 3. Plumbing i 13,0deng Permif Fee 1
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Oni
Building Permit Number: Date
Issued:
i
Signature:
Building Comm issionerP,nspector of Buildings gate
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 been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES:�1� Was
"�the permit rec/' `
orded at the Registry of Deeds?C
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body, water or-wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit be o n ed o e obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF.YES, describe size, type and location:
—. `.' .- = .• •y 4, ..:., �^+.�...:.�, u�e w qj&V 1 l i ai&0i IS 1i Bail CA Cui ttnlori PlEtrl
that vlill disturb over t acre? YES C 1 N0 0
IF YES,then a Kiorthampton Storm theater Mianagement Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New Mouse ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [oj Decks [❑ Siding[pI Other[[3
Brief Descrip' n of P oposed
Work:_ cy.� .>-�t r.�iAe 60A it P
Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing houSingCath[2Gate the foliovirr ng:
a. Use of building :One Family Two Family Other
b. Number of rods in each family unit: Number of Bathrooms
c. Is there a garage aattta ?
d. Proposed Square footage of new struction. Dimensions
e. Number of stories?
f. Method of heating? eplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschec ergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 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 Sutter Private well City water Supply
SECTION 7a-OW14ER AUTHORIZATION-TO BE COMPLETED INHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Vbc�e� �� � es rJvme'or the subject
� property SNLeyrrlaf'-hereby authorize � :�1
to act o riy behalf,in all matters relative to work authorized by this building permit application.
Signature of caner Date
I r
as Owner/Authorized
Agent hereby d;clare that the statements and information on the foregoing application are true and accurate,to the gest of n y knowi=doe
Signed under the pains an .,snaities of perjury.
Y Print Mane
Jor llelfll�l--AA/K k
k in'ature 0!`(!), art, Pant leo•;
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ` Not Applicable ❑ —t
Name of License Holder:
License Num/b�er
SQ
Address Expiration Date
Alk,
Sigh ephone
9.Registered Horne Im rovernent Contractor: Not Applicable ❑
Camnanv Name Registration Number
-ea.
Address Expiration Date
p
Telephone ) t ~� 3
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 exenIption for"homeowners"was extended to;ncli)d t :r 1-�-;3121 fazi:!-j s
and to atlow such homeowner to engage an individual for hire Who does not possess a license,11iray;ded Lhti the owner gets
as supenliseer.CMR 790, Blyth Eelitiittn Sectnon 108.3.5.1.
Detenition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intetlds 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 rnerson who constructs more than one borne in a mo-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/sire sb H be
€cct�c� silvle for all Ezuelr wgr k1 performedunder the buf1din6 tjerrnft.
As acting Construction Snpervilsox 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
ltlortharnpton Ordinances,State and Local Zoning Laves and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Mala Street, Northampton, MA 01060
Solid Waste Disposal Afndavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition 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 111, S 150A.
Address of the work: -, lZb �
r-,
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
7
/
Date Signature of Permit Applicant
The Coninionweaith ofAlassachusetts
Ojfzee of Investigations
4t
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): VCtt, ifL�� 'wefn4- , TA)Q__, —
Address: �-
City/State/Zip: `(�1��(1�1✓ 1 `(�_ �j1Vh'o2n-e #: �-(,�'�j- � ��`�1'�)2,Z
Are you an employer? Check the appropriate box: Type of project(required):
1.[ I am a employer with 19 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ 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.$
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 1 I.[] 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' 13.❑ 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.
TContractors 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 nay employees. Below is the policy and joh site
information.
Insurance Company Name: � �.._ • t � ('� w� ,!r r ;D
Policy#or Self-ins. Lic. J JJ, J Expiration Date: $ 17
Job Site Address: City/State/Zip: l�• ,��f°'1( 1 Y G ()I db2
Attach a copy of the wormers' compensation policy declaration page(sho-wing 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 civii penalties in the form of a STOP WORK ODDER and a I'me
of up to $250.00 a day against alae violator. Be advise that a cosy of .is st cm.er. inay be��:w=arded to he ire o
d tl* t #....Off,,,,.,,
Investigations of the DIA for insurance coverage rrification.
I do hereby certify the pains ar'd penadti a perjury that the information provided above is true and correct
Si ature: '? + �/ �t !� / '^�' Date:
1C3
Phone
4�Tret'in1+,Rs.n.�ea$wd. 9Do YIot wr fe ir this grgi. 1A)he a'A3mletedt bv 0tv or tow" officigl !4
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. City,/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector �-
b.Other
Contact Person: Phone#�: _-
.,>.a r A¢ ate "'� x�e _»i
L x:e i,s -O 79
268 Forcer Road
�f I
4"t
w Office of Consumer Affairs and Business Regulation
W
10 1'a�iti Plaza- Suite 5170
Boston, .Massachusetts 02 11 b
Home Improvement Contractor Registration
Registration: 105513
Type: Private Corporation
Expiration: 7117+`201& Tri! 254029 HOME IMPROVEMENT INC.
STEVEN SILVERMAII
P.O. Box 60627
FLORENCE. MA 01002
U110.ate address and return Eart#. N1ark reason for rh anoe.
Address Renewal Ernpinvrnent Lost Card