16A-020 (15) 205 FAIRWAY VLG BP-2018-1316
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-020 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeory:window replaced BUILDING PERMIT
Permit k BP-2018-1316
Project JS-2018-002342
Est.Cost: $3200.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License.
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sp ft.): Owner. ANDREW DONALD G&SANDRA WYNER ANDREW
Zoning,URA(102)/WP(17)/WSP(15)/ Applicant., VALLEY HOME IMPROVEMENT INC
AT. 205 FAIRWAY VLG
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:6/14/2018 0:00.00
TOPERFORM THE FOLLOWING WORK.-INSTALL NEW WINDOW IN EXISTING OPENING
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 6/14/20180:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Conunissioner
Department use only
City of Northampton Status of Permit
Building Department Curb CuUDriveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WatarNJell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plousita Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TVJO FAMii-y DwELLIuG
SECTION 1 -SITE INFORMATION g p- ( 9 r 1 31&
1.1 Powerlr Addness: \1 This section to be completed by office
7C)-b a t tU � 1
lb-Y—
Map 11� Lot_ ()-4 ) Unit
llle� J Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPAUTHORIBED AGENT
2.1 Owner of Record: tkNAve-W
Ntll �£6�S 11fFo� 53
Name nnl) Curtent Maili Addres.'
�l3 Sb- 1�`l0
Telephone
Signature
2.2 Authorized Agent:
a 11vev- Po 6o Gr otos Plo e. �cc MA otoc�2
Name(Print) 1 Gurtant Mailing Address:
Signature Telephone
SECTION S•€STIMATED CONSTRUCFON COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building 20(] (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from (B
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Pr LL C. Total=(1 +2+3+4+5) Check Number
This Section For Ofclal Use Only
note
Building Permit Number. Issued:
Signature. 7
Building Com oner/Inspectorof Buildings Date
Section 4. ZONING All Information(Aust He Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Requited by Zoning
This column to be filled in by
Budding Jtu' n cnt
Lot Size
Frontage
Setbacks Fmdm
Side L--R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot aeemiame bldg&paved -
azkin4)
#ofParlding Spaces
Fill:
(voWme&ineaien --
A. Has a Special Permit/Variance/Finding ever been issued fo&n the site?
NO O DONT KNOW Q YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of D ds?
r,r0 _Or.!T hN0:4� f` .SES �
IF YES: enter Brook Page and/or Document#
B. Does the site contain a brook, body of wate or.wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to obtained from the Conservation Commission?
(deeds to be obtained O Obtained O , Date Issued:
C. bo any signs exist on the prop y? YES Q NO
IF YES, describe size, ty and location:
D. Are there any propos chanees to or additions of signs intended for the property? YES 0 NO 0
tF YES, describ SP_e, type and Iodation:
-- _],ry „- �.- : 1 —. s: .. -- r:
that wdl dis on ever 1 acres YES a NO O
IF YE ,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replaconn. j{Mdows Alteration(a) Roofing E]Or Doors f�[
Accessory Bldg. ❑ Demolifion ❑ New Signs [0] Decks Siding[0) Other[OJ
Bdaf DasaiGticn gf P -pcsed
Work: nt5'k'a\� NLN/ 11Kd OW N ex 5'�Nr cieeN N� ELD x t6.t✓,P ` o 'Ffnwi tnfg
Alteration of existing bedroom_Yes No Adding new bedroom Yes �No
Attached Narrative Renovating unfinished basement Yes —No
Plans Attached Rall -Sheet NP
ea.If NeW house and or addition to existing housing. cornDEete the following: /.
a. Use of building:One Family Two Family Other /
It. Number of roams in each family unit: [lumber of Bathrooms /
c. Is there a garage attached?
d. Proposed Square footage of new constmction. Dimens' s
e. Number of stories?
I. 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'.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar door below-finished grade
k. Will building conform to the i ding and Zoning regulaflmrs? Yes Ne.
1 ! Sepiic ank_j--dy .ci Cty waorr copl iy
SECTION 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
�7111l3Yl1 "1DDr-,fid Ae�
.L ,as Owner of the subject
property C
hereby aummiza V VT` t � 1 E)AUeY 1r'0^
to act on my be r lf,in all matters relative to work authorized by this building permit application.
Signature of owner Data
I, A`Pv�Ol�lle.ViO^QO'] WE-
Agent
ZAgent hereby declare that the statements and info,me:m,..the fnreacina aoo!ica;ion are true antl accurate...ms bast of mv:mcv:edce
Signed under the pains and penalties of perjury.
�U2YN .
Print Name
olgnamre of Ownzrlhgent Data �
SECTION B-CONSTRUCTIO[J SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Nameef License Holder: �l-ttV`Cl
License Ilermer
o; - �d �� n
Atltlrass////���//p�ff�]��r Expiration Cate
S".ack'� telephone
S.Registered Home Im pavement Contractor: NotApplicable ❑
�`h nnm I�5Sy3
Company Name Registration Number
P 60-, ?''ori '; ,? 9// 7 Z0
Address r Expiration Date
B0, IPI `F�1n� ��� -a Q � Tele hone
SECTION 10-WORKERS`COMPENSATION INSURAHCE AFFIDAVIT(M.G.L.c.152,J 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affdavitwill result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... % No...... ❑
Home Owner Exemption
Tl--cvu= r .i ._ .E�r_n�-s' _�_deL r� e ,�e€Finaer oecuntled a`ceE r rc:._ti; ; r_ic'n,i�e
and to allow such homeowner to engus,e an individual for hve re'na does evt possess a license,omoyided uJalt€ha nK¢ee ac€s
as supervisor.CMR 780 Sixth Edikeou Sectio¢[gC.3.5.1.
Definition of Aorwaa mer:Person(s)who own aparcel of land on which he/she resides or intends to reside,on which there
is,or is intended m be,a me or two family dwelling,attached or detached structures accessory to such use and/or fan,
structures.A person who f C then h a n -e period=hzll not he cen€idered a hemeomner_
Such"ho roman,"shall submit w the BaDdirg Oficial, on a mini acceptable to the Building Ofdcal.chat he/she shsh be
,spe.gEhle for all sach work per Decreed audev th e 6,fFdi o nelsit
As octlng Co¢strmedon Supervisor your presence on the job site will be required n'om time to time,during and upon
completion of the work for which this permit is issaed.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter l53(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Amotafed,you may be liable for person(s)
you hhn to perform work for you under this permit
The undersigned"homeowe el'certifies and assumes responsibility for compliance with the State Building Code,City of
Norrhampta,Or'd'inances,State and Local Zoning Laws aad State of Massachusetts General Laws Armotated.
Home awn.. 11a -
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
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: 20S bua �CdS
The debris will be transported by\:, y(p� IO4n�7}'}QCnf 4nFyo4e oeK- -
The debris will be received by:
Building permit number:
Name of Permit Applicant O
ro
Date Signature of Permit Applicant
The Commonwealth of.Massachuseits
_ Department oflndustriatAceidents
114 -- ` Cfjace of Investigations
600 Washington Street
;7 Boston, MA 02111
= www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letsfbly
Name (Business/Organizatiambdividual): y[� 1,1 \(' n4- , TV)
Address: i,� `
City/State/Zip:
Are you an employer? Check ptithe appropriate box: Type of project(required):
1. ] I am a employer with )U 4. E] I am a general contractor and I
employees(full and/orpart-tune).
s 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 S. ❑Demolition
working for me in.any capacity. employees and have workers'
insurance.;
req 9. E]Building addition
workers' compcorap,insurance
required.] 5. ❑ We are a corporation and its 10.❑Elechical repairs or additions
3.❑ 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' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#t most also Of out the section below showing their workers'compeesatme policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mostsubmit anew affidavit indicating such. '
;Contractors that check this bas most attached an additional sheet showing the name of the sub-coatiaaors and state whether or not those entities have
employees. tithe subcontractors have employees,they mustprovide their wmk os'comp.polity number.
I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
information. n
Insurance Company Name: f�VbeMO-
r
Policy _ ,:� . t✓��/l�n,• tom'— - . 1
o.. r ,. tee..-ms. �:c. ��.. 1Z-�...� _ -____..>:xpsaticn Date: u '`t 'I.
Sob Site Address: ZOS u_atA \AVkLYI- City/State/Zip: 4,n!is Ao o1be�,3
Attach a copy of the workers' compensa on policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c.452-catFkadtothe imposition of criminal penalties of a
fine up to $1,500.00 andler one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER wad a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverageLrIcation.
I do hereby certify t the pains a�C penahi perjury that the information provided above is true and correct
1
5i®ature: - .%'/>ed�^ Date �I�I)
Phone#: Ml"22_
Official use only. Do not write in this area,to be completed by city or town effcial it
City or Town: Permit/Liceme#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CYty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Persen: P;paz#:
17commonwealthOf Massachusetts
Division of Pmlessional Licensure
Board of Building Regulations and Standards
Cons(rµct�t{a$d p�ry i s o r
CS-077279 E�pires: 06/21/2020
STEVEN A SILVERMAfJ I
268 FOMER ROAD �l .f! O%
SOUTHAMPTON�•1A It'.' ,
17J/SS330�y
Commissioner L,
C���ie 016 G WaoGal
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
— Registration: 105543
Type: Private Corporation
INCA ,l
Expiration: 7/17/2018 TM 419291
VALLEY HOME IMPROVEMENT
STEVEN SILVERMAN J,.
P.O. Box 60627
FLORENCE, MA 01062 cj
Update Address aad return card.Mark reason for change.
scat tam-osn�
Address L] Renewal 0 Employment n Lost Card
O
C97/e�omn,runuoaa!!/e��i�(iimac/uwelG
Office fCmm.rr Attains&Basmesa Rit lafioo License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 105543 Type: Office of Consumer Affairs and Business Regulation
Expiration 7JI712018 Private Corporation 10 Park Plan-Suite 5170
"' — Boston,MA 02116
VALLEY HOME IMPROVEMENT INC.
STEVEN SILVERMAN
340 RlversldeDr
Northampton,MA 01060 _ Undersecretary Not valid without signature