12C-046 (3) O ,ItA1HP lO
e,, Gitg of Northampton -*
B Vii. Vi r� lasaz scknsetts _ =
` �- DEPARTMENT OP BUILDING INSPECTIONS 4 q `
212 Main Street 'Municipal Building '
. Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, , sLSOAr it hl%W7 1 l/.9 -'-LP' //0/11 vs e4/, J L
(licenseclpermittee)
with a principal place of business/residence at:
3 `•0 /<11/__,-.5 Lb 2 i)nli / � /a,e-/7fnt.r7i�ia/l; lid (phone #) 58 ¥- ZZ.
(str=t/city /s',ate/zip) NO6 0
do hereby certif under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job: .
Acadia Insurance Company WCA5029908 2/1/2013 "
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor 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 Comrpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnecossary to include information pertaining to all contactors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do pr. 4 +t••+ *an, construction or rcpair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's oc ration Act (GL152 ss 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this stam:nem may be forwarded to the Depertmcad of Industrial Accidents' Office of Ixnuraoce 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 ofup to 51,500.00 and/or imprisonment of up to one year and d vii penalties in the form of a Stop Work. Order and a
fine of S 100.00 a day against me.
Signed this . / _ day of ii-4 201& For departrentel use only
Permit Number
I • J�1I ` /it¢a. Map# ,Lot #
Signature of IS.. - • ermittee -
6:79 t t.,941424‘itrwA
, ley
Office of Consumer Affairs and Business Regulation
\lit;
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 131945
Type: Individual
Expiration 10/13/2012 Tr# 204590
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD. „
SOUTHAMPTON, MA 01073
Update Address anti return card. Mark reason for change.
Address ' Renewal fl Employment 1 Lost Card
50M -04:0441101.M
19 wdoerzia ett
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 131945 Type: Office of Consumer Affairs and Business Regulation
Expiration: JO/13/2012 Endwiduat 10 Park Plaza - Suite 5170
Boston, MA 02116
STEVEN A. SILVERMAN
STEVEN SILVERMAN '
/
268 FOMER RD. „,„
SOUTHAMPTON, MA 01073
UndtrSeC re ta ry Not a1 w thout signature
400
lttas. - Department of Public Sulet:i
fiwtrd of Builtlint Rettuttuiion and StAndards
Construction Suporwisor License
License. Cs 77279
Restrictetita: 0
STEVEN A SILVERMAN
268 FOMER '
SOUTHAMPTON, MA 01073
Exoirottont 6121120
Tr#: 26868
■,aulti-soot t
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S Sliver iaYL_ 077279 —
License Number
268 Forcer Road, outham trrn MA 01f173 6/21/12
Address Expiration Date
584 -7522
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman.._ __._ 131945
Company Name Registration Number
268 Fomer Road _ m ___� 10/13/12 �.
Address Expiration Date
Southampton, MA 01073 _Telephone 584 -7522
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 108.3.5.1.
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 may be 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
•ccrtgN 5- DESCRIPTION OF PROPOSED WORK (check all appIidahls)
•
New House LI: Addition Li RepIacepe1it Windows Alteration(s) Rooting fl
Or Doors .
Accessory Bldg. Demolitior New Signs Decks ; 3 Siding f Other
E- 1c.4 Dr:/,;(:,'•//y, or /10 )41.6,o,ra
\lc p",1/;:i
Lo:yrint:/"1
Pb' AtCauhcc*5 Po!'
6. If New house and or addition to existing housing, complete the following:
J't rani ty rartidy
b %titnni/' f,/t
tuctlpitl PI! I !.17.` ,%(..//01/„,/t.t :)1
f. Ve',Hod ijf I r Wocat,tuv r\u odch
CorT, ia ts/E Eme-gy C:4abl.F.At:e form a".tacl cb?_„
10:) 't v.et Yes v 100 rt.
f ofi c I rr 'iediee
M1 •
CLe,:f forffi c Ie I3uIi cod 2r',F;
• Sti.tiC K C CA:y water 5,1')E) y
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-
/5/,dd /$5 5/77 / 7774 , as 0..vrtet ct t subject va;Arty
,'Iu!nrirl7P Steven Silve .1 , Valley Home Improvement, Inc. nt
my 17.' /// ..;; b.„,/:::f FIR ;',,e/r it aor)1K,fic--1
—
/ ti■e„d1 4 ,40 l i ffi
.41/1
Siaacure ut Owier V7S
. _
—SteXen Silyexnian Valley Home Impromement,Lno. , fAlitrifYI7E1 AE(70
dec ate ":ne stetrie71v, 11(f ir/foir of/ or/ tIii f oir pi.:.//cifto// Yu nfj Ett ivy
cz lee CC
a nc
SI:77cd .• "te
Steven Silve Er.
/./r %■YrN!
/ 7z-7
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing 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 ary proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
S
I
r__..._w______ Department use only
F ;EC 'vE City of Northampton Status of P �rf i,.#
1 Building Department Curb Cut /6ribeway f' �r nit .
MAY 2 2 2012 212 Main Street Sewer /Septic Availab�itity 7 .
Room 100 W ` r /Well Availability A-
rthampton MA 01060 1' Sets of ''aural Plans ,,
DEPT. OF BUIw ;r.� ' > . v � � a
NORTHAMP � '•0-" :,7 1240 Fax 413_587_1272
Plot /Site P i i,X.
Other Specg -, ;- , .
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
./Cc-
J / z c'c -,/l� %1 '/" -.- Map Lot Unit
�' /- 0/ j /j C L / ///, � `C / , �. 2
_ Zone Overlay District
Elm St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _6' e c �iL (' /lie i� z
/;/ZeCA. : t rf- ISS /'- S7 /77,--- /-/( `t, t/"/ c 7/1,/ 0 / C Ce 2_
Name (Pr' ) Current Mailing Address: >.
Telephone . J
Signature ,, ' C 3 (- - C� 2 9'
:7
2.2 Authorized Agent: Steven Silverman
Valle Home Im•rovem =,. s P.O. Box 60627, Florence, MA 01062
Name (Print) , ' I Current Mailing Address:
iI 584 -7522 _____
Signature - Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building c0 (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) J) 611) Check Number 6 11 3 C-
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date