39A-065 (2) tioArd - t Bihkn Ro.,2031 'NtIntfarth
ConStrucl"lc SupPrv“Ir Lc
LicPt Cs 77279
Ro.friptPq t. 0
STEVEN A SILVERMAN
268 FOMER RD
SOUTHAMPTON, MA 01073
L.,pdatp.m. 6212012
r Tor 26868
tiort.r.4pt .1.414idirrokoart‘t i a6d NtIrrirtir
Licenw or rew. d for indr‘ uNe ont,
HOME IMPROVEMENT CONTRACTOR before the expiration date. If f;rood return to:
Registraton' '3'045 Board r atirlden„ 1. and Standard,.
()op A,Itdirton Place Rtn 1301
Expiration: 10.(1.3,20.!G Trg "
Boston. M. 02,10N
Type: Inamcow
//
STEVEN A SILVERMAN "
STEVEN SILVERMAN
288 FOMER RD
SOUTHAMPTON ,i'/A 0 1073 Admirostratin " %Aid without signAture
r o4 -,t1ANlp�
� _ °� �:• Eat of ortha lept i — * - u
r cure - _
�`l : i0 a Alassaclinsette =e_ t=
DEPARTMENT OF BUILDING INSPECTIONS _
•
212 Main Street 'Municipal Building o, ,
Northampton, Mass. 01060 W'
WORKER'S COMPENSATION DiSITRANCE AFFIDAVIT
/ � �� e!- ,Sr"? 5%i /','': L/,i�1� = 5 /f%s'iL. L y _:''% 77%l�.;t4 i
(licensee/permittee)
with a principal place of business/residence at:
3 `to .J ✓%-te /62 J, -Ve „A/-'1 ,;"l (phone #) `a 4 /- 7')
(s treet/eity /s,a to ip) G5 e
do hereby certify, under the pains and penalties of perjury, that:
I ant an employer providing the following worker's compensation coverage for my
employees working on this job:
(insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general conuactor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) ( Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnecessary to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do roain>rrratsre, construction or repair work on a dwelling of
not more than three unite in which the homeowner resides or on the groin appurtenant thereto are not generally c oc lid red to be
employers under the worker's compeasatica Act (GL152,ss 1(5)), application by a homeowner for a license oc permit may evidence the
legal dams of an employer under the Work.oes Compensation Asa.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidenne Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MQL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fins of 5100.00 a day against me.
Signed this > day of / 4 i r >,i' co For use only
l � ,/1 Permit Number
//// i� / '- Lot #
Signature of Wensee/Permittee
•
': SECTION 8 - CONSTRUCTION SERVICES
r
,1 Licensed Construction Supordisor: , Nat . p'i ^.ICI., .. -i
s,,) c'€ ui ;•::} Holder . Steven Silverman — 077279
268Fomer Road So' t iamDt_on, 111 073 6/21/12.
-less J C i:ra Date
/l.
584 -7522
ele1 m?
i I
9,.R_? Stored Home Improvement Contractor: Not ,A,pnli can e 11
Steven Silverman 1319ttq
Company fame Roost ICI bcir
268 Forcer Road 1 0 /131_.p +�
Adid Exoiration D t
i
Southampton, MA 01073 Toicphone 584 -7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. e. 152, §25C(6)) 1
WoriKers Compensation Insurance affidavit must be completed and submitted with 1h s appl ca11irert. failure to proving this alficavit
res;tit l,1 the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X 9 " so 0
. -. - Home Owner Exe n ytion
The current exemption for "homeowners" was e \te,ld..cl 10 include Owner- occnpied Dwellings ()Cone (I) or 11 0( Icin < 111�,.'s
and to allow such homeowner to engage an individual for hire, wvho does not possess a license, provided that teat oWnCr aCtS
S`s supervisor. C.N111 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on wwhich hL she resides or in bads to reside, on there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or laved
structures. A person who constructs more than one home in a two -year period shall not he considered a homeowner.
ner.
Such "'homeowner" shall submit to the Building Official. on a form acceptable to the Building Official, that lie .tshe snail 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 tiilmc during and a('011
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 15 (Liability of mpioy01 to
Employees for injuries not resulting in Death) of the Massachusetts General Lawns Annotated. von amav be liable tc >, 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 or Massachusetts Genera! Laws Annotated.
Homeowner Signature
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;;ECT "'Ol"1 71. OW'i P AU RI AT O 1 - TO OE CONZPLCT O WHEN
WMERS AGENT OP 'CONTRF,CTOP A R".R1 IPS FOP 13s,i',x)t'. PERMIT
6 Fr /n,"f 4
Shaven Silverman, Valley Home Improvement, Inc.
e W1 0 1 , 1, ca.- 1\ /. IA (1
7/17
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1 . Steven___Siiverzi n, Valley ,, >Hone _- .Irtproyernent, _Inc m •
1
Steven Silve an
, 07/0/ 0
Section 4.
ALL 'INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DTJE TO LACK OF INFORMATION
Existing I 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
.
•
Department use only
City of Northampton Status of Permit:
Building Department Curb CutiDriveway Permit_
212 Main Street Sewer/Septic ;Availability
_;
Room 100 Water /Well Availability
Northampton, MA 01060 'Two Sets of Structural Plans_
phone 413- 587.1240 Fax 413. 587 -1272 Plot /Site Plars ��._., ` I
Other Specify__ .— I
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1
his , o to he completed by office
1.1 Property Address:
w /779fii ® 772/e _ Map Lot Unit
�.2/i (5 /C) (e Zone ._ Overlay Diistrict�----- - - - - --
Elm St. District_ CB District__
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ,/ `0 /14-7?-7•" �
—._ fi42m/ / / 1X ,dGv714 ?%- / c)
Name (Print) Current Mailing Address:
h r �� __ Telephone 9 --
Signature ��
2.2 Authorized Agent: Steven Silverman
Valley Home Im•rov -J -nt, Inc. P.O. Box 60627, Florence, MA 01062
Name (Prim t/ Current Mailing Address:
584 -7522
Sigr:atur Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
i
1. Building — . 5 up (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing `_ Building Permit Fee
r
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) (0 1 (Q Check Number / (7 1-Qa
This Section For Official Use Only
Building Permit Numb - : ' Date Issued:__
Signacu R:
.uliding Commissioner /Inspector of Buildings Date — —
10 HAMPTON TER BP- 2011 -0280
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0280
Project # JS- 2011- 000468
Est. Cost: $6100.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 58806.00 Owner: KAPLAN EMMA N
Zoning: SC(49) /URB(51)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 10 HAMPTON TER
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:9/27/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 3RD FLR SHOWER
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 9/27/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner