38B-127 (3) 40 COLUMBUS AVE BP-2020-1063
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B- 127 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-2020-1063
Proiect# JS-2020-001800
Est.Cost: $4000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 10497.96 Owner: JOELSON JOHN M&JOANNE LEVIN TRUSTEES
Zoning: URB(100)/ Applicant. VALLEY HOME IMPROVEMENT INC
AT. 40 COLUMBUS AVE
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:4/20/2020 0.00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF ON BACK OF HOUSE
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 Sip-nature:
FeeType: Date Paid: Amount:
Building 4/20/2020 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
6
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APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING
SECTION-1 -SITE INFORMATION' -."..
This section t6be completed by office a a
1.1 Property Address: q {/��}'{ �p MapiP
r{ �,� yt�V� 5jF.
lO Co\ )uVI a'✓VS 1 .i „�t./` ISlr3.p _+a.3 `�. l`lrtll.�' F t'# '�
Ione Ove�l ty€}rstrret. a Pt
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Elm St. District:- (. :� _. _ Ce'blstnct: a. f
SECTION 2:-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
TOO-xn(-It e_y _0C_k Scx� q o7 Co I o,-j,h c —4�h=j2 zr,
Name rint) Current Mailing Address:
Telephone
Sig ature
2.2 Authorized Agent:
cam- . I ���r C P O•(�aX �O�a1, �lore�-�c� (� O►(�LZ
Name(Print Current Mailing Address:
X13—5��1-�522
Signature Telephone
SECTION`3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6): '.
3. Plumbing Building Permit Fee .
v
4. Mechanical(HVAC)
5. Fire Protection i :•"
6. Total=0 +2+ 3 +4+5) Check Number _
/hlnThis.Section:For.Official:Use:Only
Building Permit Number:69^�'0 ~ <</1�� IDssued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF.PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alterations) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[[:A
Brief Description of Proposed �S I _ �el C
Work: ►1CC� 1/� IIVvI
Alteration of existing bedroom Yes No Adding new bedroom Yes Nd�
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New=hause'.and or addition to'ex[stnq hosng, complete the`folfowtng:
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 ORCONTRACTORAPPLIE&FOR BUILDING PERMIT
I, 13 0—D ni— �f.tv✓l in 12h 'bCk5Cn as Owner of the subject
property
hereby authorize � l E+-eAscn & l Q ermccr)
to act be If, in all matters relative to work authorized by this building permit application.
,'� 5 Z 3 azo
Sign ure of Owner. Date
I. 2A-eA_'yr.►'1 sI V R- r 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.
eQ-e n �JQ-e_rry-ian db
Print Name
Signature of Owner/Agent Date
City of Northampton
,•,�, _� .. Stis,w... sic
Massachusetts � ' •. c�
DEPARTMENT OF BUILDING INSPECTIONS
- ' 212 Main Street • Municipal Building
......... .- Northampton,.,MA 01060 .".A
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 as 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 of WorkEst. Cost:
Address of Work: 140 Cp((_,V �
Date of Permit Application: 3o.— OW a O
I hereby certify that:
Registration is not required for the following reason(-):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WI'T'H 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 RESPONSIBILTTES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
cu oft< ►,&,T i-A -51 c X055 y 3
Date Contract6r Name HIC 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
Massachusetts
. _ DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building Jj a'
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:
v4cp Cc)
(Please print house number and street name)
Is to be disposed of at:
�R-Ufm Njcj-wi)'J� —
(Ple ` e print nd e and locatfon of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
A
Signature of P'erfVif licant or wner 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.
r
Commonwealth of Massachusetts
®�
Division of Professional Licensure
Board of Building Regulations and Standards
Con st\�ct1"SNbSpe_rvisor
lJ
CS-077279 :> "� "�p ires: 06/21/2020
STEVE
NAsOVERM•Af�. '=' ^
268 FOMER R6j4D
SOUTHAMPTON%�dIA•-010_73 aQ
��OI,SS330�S
Commissioner
-12 2,,1-�n I'M,6 4e.'��e elze �/L ,
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement�-Coo�ntractor Registration
Type: Corporation
VALLEYHOME IMPROVEMENT INC
P.O.BOX 60627 t 7 Registration: 105543
r
Expiration: 07/16/2020
FLORENCE,MA 01062 y =7
�c
/tet/
ludy `,ra{ •
Update Address and Return Card.
t c, 2OM-05/17 ,
�in�irecveae¢ll�a�,��a��ad�ulell� .
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:,Corooration before the expiration date. if found return to:
ReaIstr.`atron. Expiration Office of Consumer Affairs and Business Regulation
D5543 07/16/2020 One Ashburton Place-Suite 1301
MBEF
VALLEY HOMEiIMP_EtQVEk�ET'- NC Boston,MA 02108
kEVEN A.SILVERMAN
-- !
340 RIVERS IDEDR�4�,�%
NORTHAMPTON,MA 0-1 Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston, MA 02114-2017
.• 'y www mass.govldia
lVorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERI%HTTING AUTHORITY.
Applicant information Please Print i eaibly
Name (Business/Organization/Individual):
Address: '�-�O ��ve,rs��l �r►�rc rl� O P�ozc (c�0(�21
City/State/Zip: F 10re,nCC_ kC-� 01 00-2- Phone
Are you an employer?Check the appropriate box: TypeOf project(required):
I Z I am a employer with employees(full and/or part-time).• 7. []ON,
New construction
2.r_1 I am a sole proprietor or partnership and have no employees working for me in g. 0 Remodeling
any capacity.[No workers'comp.insurance required.l
01 am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9• ❑Demolition'
I.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
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 r additions
5.❑1 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.insuranre.t 13.❑Roof repairs
o F]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.rNo workers'comp,insurance required.l
*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 ani an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. p
Insurance Company Name: -A} -bC (L 7,nC—Ur n t„t_ CQ VI C>�No
Policy#or Self-ins.Lic.#:_ Qi5eJ50 3 y 2\S Expiration Date: o? 1 t
Job Site Address: -LV l,C���'` YC City/State/Zip:_ �(C�U I Ulod
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.
Ido hereby certify un er the pains and pe (ties of p hat the information provided above is true and correct
Signature: Date:
/,;io aoav
Phone#: �J'15214--1 S22-
Official
2ZOfficial 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#: