17C-041 (8) 63 SHEFFIELD LN BP-2017-0626
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mapiflock: 17C-041 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Skylight BUILDING PERMIT
Permit BP-2017-0626
Project# JS-2017-001011
Est.Cost: $4500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot size(sft. ft.): 15725.16 Owner: CHODOS LEIGH
Zonine:URB(100)/URA(0)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 63 SHEFFIELD LN
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
F L O R E N C E MA01062 ISSUED ON.:II/3/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 2 SKYLIGHTS, NO CHANGE TO
FRAMING -VELUX M04 UNITS
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 11/3/20160:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0626
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 63 SHEFFIELD LN
MAP 17C PARCEL 041 001 ZONE URB(100)/URA(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
��
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: REPLACE 2 SKYLIGHTS,NO CHANGE TO FRAMING-VELUX M04 UNITS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
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
INFOf�MATION 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
Si . - • eofB. •- gO' mal Date
Note: 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.
i! ^ Department use only
i \ City of Northampton status of Remit
Building Department Curb Cut/Driveway Per mit
> 212 Main Street Sewer/Septic Availability
/` Ito 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: This section to be completed by office
/03 She$$iicld LL.nC Map Lot Unit
\-larein .G Zone Overlay District
Elm St.District Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LetT, incduS t3 Shek4tcc k ane FUxence 'aka Oto02
Name(Print) Current Mai ng Addres
I7- 03-$1$I
������ _
eephone
Signature as..."
2.2 Authorized Anent: p
3vCs ev, S r2.ivY\4 r• P.O. & C 1 a1 t=laenrr Mc: otos
Name(Print) Current Mailing Address:
/-{��/�//{/I'�(�/ /�////' A. „it_ s._-„,as
Signature <'”" " ✓ ° Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 't 5- (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) Check Number ia7 1/II V
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
(yr
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he flied 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)
N of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever/been issued for/on the site?
NO O DONT KNOW O j YES O
IF YES, date issued:
IF YES: Was the permit recorded at the R gistry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body f water or wetlands? NO Q DONT KNOW O YES O
IF YES, has a permit been or n d to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
(
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction 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 0 NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacem nt Windows Alteration(s) n Roofing In
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[C] Other[0]
Brief Description of Proposed -c - c/;
Work: RL�1-�V�G 1 ?�ry 4k-Y �( c — - No "NA,N` . TDpp f Kw �d
Alteration of existing bedroom Yes 7'No Adding new bedroom Yes 7C N V u-(K M04 linos
Attached Narrative Renovating unfinished basement Yes T No
Plans Attached Roll -Sheet
ea. 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. Massdteck 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
I, L e\ P C) Q'3¼.)-5 ,as Owner of the subject
property
hereby authorize & I ! 1LC„' L 1./Y-0-5017V—A-74—
to
J-5 17V—A -
to act on -- alb,in all m-• rte- to work autho 'zed by this building permit application.
Signature of ili >r Date
I, Ve n x\ ajar
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
arid Le6eL
Signed under the pains and penalties of perjury.
S\'C\.til l ‘...31C-r✓vmex
PrintName ))
(///A L�( 2
Signature of Owner/Ag nA t Date /
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction`Supervisor: Not Applicable 0
Name of License Holder: . 0.11r—n S1\'cs`YV1CUM 011 a-19
License Number
z , �md 5 p\n Ma c)1C13 lo ►u I i b
Addressi, 1 Expiration Date
All' Iti v= - . - -_
Signa 5 - Telephone
9.Registered Home linrovement Contractor: Not Applicable 0
°Thke x, -:Th)\\yrev Ccs /05593
Company Name Registration Number
iO . 6ox, & o6F a`7 91/ 71/8
Addresssy(L�1
s 1� ` G Expiration Dale
'IC( WA
_. �/�, 0\V i'ie Telephone sp Ut-Th
-
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 1083.5,1.
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 maybe 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
City of Northampton 212 Main Street,Northampton, MA 01060
Solid Waste Disnosai Affidavit
In accordance of the provisions of MGL c 40, 354, 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: 193 Shcc4 1e✓ t-w "
The debris will be transported by: QJ,,Qa C1YY yasse_Xnpxi--
The debris will be received by: a J? c ckj
Building permitpumber: U �J
Name of Permit Applicant '\)Gtat 7. , t •vniCr iP_A-31
112,A) 'dr', H
/
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): yQ\ U, C .1-V`Yl p(C Vn/')Cn--- , -TAn
Address: 3 \b t`Sf Y Cie \tom I
City/State/Zip: 1" \D/€n.Le ' Q\-Phone #:__,,,
Are you an employer? Check the appropriate box: Type of project(required):
I.a ty I am a employer with 1.123 4. 0 I am a general contractor and I 6 ❑New construction
employees(full and/or pan-tune)." have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers'comp. insurance comp_insurance.:
required.] 5. 0 We arc a corporation and its 10.0 Electrical repairs or additions
3.0 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#t must also fill out the section below showing their workers compensation policy information.
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 shat 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. f� om,
Insurance Company Name: AY sljv�. CL t t ' `z t '-e . n
Policy n or Self-ins. Lie,0: SL^O',c3O3O'Z S Expiration Date: a b (7
Job Site Address: s# " . I _,,,City/state/zip:Tkorra(i 49(- Ob 2-
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 dfrcation.
Ida hereby certify o • the pains a rid penalt' perjury that the information provided above is true and correct.
Signature: '- (t2, uyflw "" Date: 1l 241 coPhone#: AVD-�SOp L"�.—Iac
._. , q..
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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#:
acc 3 g :Hf
(,cern CS-077279
STEVEN A SILVERMAN
258 FOMER ROAD
SOUTHAMPTON MA 01075
1 -
Expiration
Commssioncr 06/2112018
F
OfticeofConsumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 0.:116
Home Improvement Contractor Registration
Registrz5on. 106543
Type. Private Corcoralion
Exprraban: 71177,018 Tr: 41 191
VALLEY HOME IMPROVEMENT INC.
STEVEN SILVERMAN
P.O. Box 60627
FLORENCE, MA 01062 _... ._ ._
s .r tipEmo' m Loi C
Ofrcr oft on of(orntriner kffairsXN xR ,=vntn>u License or registration valid for i ndindua1 use only
r^. HOME IMPROVEMENT CONTRACTOR oior uu r .
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