23A-188 (3) 136 SOUTH MAIN ST BP-2020-1029
GIS#: i COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 188 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2020-1029
Project# JS-2020-001736
Est.Cost: $27500.00
Fee: $178.75 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq.ft.): 40946.40 Owner. COOPER RICHARD E&CATHERINE M
zoning: URB(100) Applicant. VALLEY HOME IMPROVEMENT INC
AT. 136 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (41.3) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/16/2020 0:00:00
TO PERFORM THE FOLLOWING WORK 2ND FLOOR BATH RENO
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: (lough: 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 3/16/2020 0:00:00 $178.75
12 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use ori[y
1'ek.FEe Orr i t?� .��t'• r L'Y r.�"�_ra N
City of Northam. Ir�' Status afPermtt wigh , � x '
Building Departmentlit-
' Gut/Drcvevay Peirrt�t� ��u-� �aM L ratter=x
_y 212 Main Sttee��gA ewer/ epbc-AVgga��ilabtltty w 5 fi i eii z c f k3 Aye+ .r
M� On
Room 100 afar eUAvailabiltty 4
NorthamptontiM WAR
1060 �� Twa ets olaStr�tctural PEansts �' a �� t� 3:
phone 413-587-1240 Fax ' -1272
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'oh �spEC Ot erSpecttj
APPLICATION TO CONSTRUCT,ALTER,REPAIR, R&ZO QR D MOLISH A.ONE OR TWO FAMILY DWELLING
SECTION 1:-SIT'E INFORMATION
i This section to be compEeted by officer 4 g �g n
1.1 Property Address:
1 7t0 cl • ' �* a p #t y E Ot i �a F i' a F, t '.
Ma _ db5 syV.
Unit
Elm St DistncDISIrch:
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
g�C)IOakdoor�rk� 1 1 13to �ol6Z
Name(Print) �T— Current Mailing Address:
Lf 1 sk-3 - OgSy
Telephone
Signature
2.2 Authorized Agent:
t Qer Ct` P O•�b`�c (gueD Dore%-�cc� 1�1A- O►C�(�Z
Name(Print) Current Mailing Address:
A& 2 4t3-59y-`1522
Signature Telephone
SECTION'3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official:Use Only
completed by permit applicant
1. Building (a}Building Permit Fee
2 L1, ODU
2. Electrical o_ (b) Estimated Total Cost of
S Construction from(6):
3. Plumbing a)U Building Permit Fee .
/.'' s
4. Mechanical(HVAC) / 7 t Z
5. Fire Protectionji
6. Total=(1 +2+ 3 +4+5) a7 SQQ Check Number _ 5
"nn !!,, This.Section For.Official Use Only
Building Permit Number:LY- �V' /0011 IDssued:
Signature: 3 )
UU
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 I
Frontage
31
Setbacks Front
Side L:= R:= L:= R--
Rear
Rear �-
Building Height s
Bldg. Square Footage i % i-,,
�?
f F
Open Space Footage %
(Lot area minus bldg&paved { 1 ! I
arida )
#of Parking Spaces '
Fill: _ I
volume&Location) 1Z 11 --�—
A. Has a Special Permit/Variance/Finding ever bee issued for/on the site?
NO 0 DON'T KNOW C) YES 0
IF YES, date issued:.
IF YES: Was the permit recorded at the Re ' try of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book ` Page; and/or Document#'
B. Does the site contain a brook, body f water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or n ed to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the operty? YES 0 NO
IF YES, describe size, ype and location: i
D. Are there any propo d changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construc'on activitydisturb(clearing, radia excavation,or fillip over 1 acre or is it art of a common Ian
� 9.9 9. 9) P P
that will disturb ver 1 acre? YES NO 0
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 ❑ Replacement Windows Alteration(s) En Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [Q Siding [O] Other[CI]
Brief Description of Pr posed
Work: 2`'$ rLoW- Aaj ILPM60 tt - 00 Cq46 F Td 5-7-4U f C-�-(d 4 L 1l:�2{0/4/1),v�
Alteration of existing bedroom Yes No Adding new bedroom Yes No 'vU
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa..Cf�New_house'andor addi#'ion.to exist r q housing, comple#e the folfovritnc:
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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a.-OWNER AUTHORIZATION-TO BE COMPLETED.WHEN
OWNERS:AGENT OR CONTRACTOR.APPLIE&FOR BUILDING PERMIT
k- as Owner of the subject
property
hereby authorize }}= I ��n c71 1V frMCc-r'7
to act on my behalf, in 211 matters relative to work authorized by this building permit application.
3 cc
Signature of Owner Date
I. DT,-)-c—t'1 �I I�►e-r'mQ�-� `f 144 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.
-e�92-r1 � ��➢'er
Print Name
Signature of O A en Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: C Not Applicable El
q
Name of License Holder: C ?T�V � V 11 L�1 1\�1 l 0-1-7,-)
/
License Number
1 (L-)2-
- c, JaI /aa
Address \ Expiration Date
`-�1�-58�►-�5aa
Signature Telephone
9-Registered
Not Applicable ❑
o
Hme.img%vementContractor _ MUM
_$
10 UP 10 c56 X13
Company N e Registration Number
P-b - bbl- (0 DO D-3 EtQ(M(G U1Qb2 `I �
Address Expiration Date
Telephone q�3-59q-7JZz
SECTION 10-WORKERS'CO MPENSATION.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...... ❑
i
i
City of Northampton
Massachusetts-
DEPARTMENT
assachusetts DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton,,.MA 01060 Jbyyr ��
—� AFFIDAVIT-
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR')regulates the registration of contractors and-
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes, a contractor must be registered ad a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization,conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by reastered contractors.
Note:If the homeowner has contracted_with
-a corporation or LLC,that entity must be registered-
Type
egistered
Type of Work �q�l-� ►�st.11Y1C701R� Est. Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reasorl(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEM OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILPTES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of,pe&ry:
I hereby apply for a building permit as the agent of the owner:
11 <,-'hema)r C 10 5co x-13
Date Contract6r Name MC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City_ of Northampton
•,x r5 rte- s+♦
�4-t Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS YL
212 Main Street • Municipal Building W" 1b`
Northampton, MA 01060 r�Y..�j�
Massachusetts Residential Building Code
Section 110.R5.1.2
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.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
I
City of Northampton
S,� =_...s,�;•
i Massachusetts 4$ c
^�11 DEPARTMENT OF BUILDING INSPECTIONS
' y 212 Main Street •Municipal Building �yiy c
! Y Northampton, MA 01060
Debris 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.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
% - V kC \D 1\bA�l
(Ple ` e print nd e and locaeon of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature/of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
l
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
,M www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED RTTH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbly
Name (Business/0rganization/Individual): \�, ,I-P,U 1(. 11 f ro,,em e� t—Sh L
Address:
City/State/Zip: "Fkxence, X41 D\bb`Z Phone#: �13-5g`�'15aa
Are you an employer?Check the appropriate box: Type of project(required):
1.EgI am a employer with 18 mployees(full and/or part-time).' 7. ❑New construction
2.❑I am a sole proprietor or partnership andhave no employees working forme in 8. M Remodeling
any'capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required-]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp.insurance= 13.[:]Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,$1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fin 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: 71 C1su-0-'Y,t? 6 vnt%
Policy#or Self-ins.Lic.M Q OCC&Q302-\S Expiration Date:
Job Site Address: l'��D �(O1�1'i si- City/State/Zip: t W✓e.V 1w olc)(OZ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and enalties of erjury that the information provided above is true and correct
Signature: / Date:
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 M
®. Commonwealth of Massachusetts
J Division of Professional Licensure
Board of Building Regulations and Standards
Const\� pe,rvisor
�J
CS-077279 _> E ires:06121/2020
STEVEN A SIL-VERMAN ;.;a; ^
268 FOMER ROD
SOUTHAMPTON=VIA
'GC� L%
Commissioner
052
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement,-Contractor Registration
�
� Type: Corporation
!
VALLEY HOME IMPROVEMENT INC "' �� T Registration: 105543
P.O.BOX 60627 `C Expiration: 07/16/2020
FLORENCE, MA 01062
,.
—li Update Address and Return Card.
1 C� 20M-05/17
✓�� �in7m-cizcc�¢C°l�cy�,/j�¢�.1¢��,telli
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Reoistration\ Expiration Office of Consumer Affairs and Business Regulation
05543 07/16/2020 One Ashburton Place-Suite 1301
VALLEY HOME(iMCR------]EN:>INC Boston,MA 02108
STEVEN A.SILVERMANiig
340 RIVERSIDEDR
NORTHAMPTON,MA 01062 ndersecretaiY Not valid without signature