16B-001 (3) •
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` �'� DEPARTMENT OP BUILDING INSPECTIONS _` t_=`
• 212 Main Street • Municipal Building ' a .
Northampton, Mass. 01060 ow
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, WELSOAr SW /G P%L &7% _, l//tez /1 P ffo/L -e_ L�7/zG'l/ 1% 221c
(Iicenseelpermittee)
with a principal place of business/residence at:
3 "fo /1 /Z.4.5 Lb 2 Z I-11Z j //0,�2f ,7 ; ii/.4 (phone #) 5 7Z2.._
(street/city /stattip) el/Oh 0
do hereby certify, 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shoot ifnecevary to include information pertaining to all contractors)
( ) 1 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 maintenance, coossruction repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant tbeteto arc not generally maid: red to be
employees under the worker's compensstion Act (GL152, s 1(5)), application by a homeowner fora license cc permit may evidence the
legal status of as employer under the Worker's Compensation Act
I understand that a copy of this statement may be foewerded to the Department of Ir striel Accidents' Office of Issuance for the
coverage verification and that failure to secure coverage under section 25A of MQL 152 can lead io 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
fine of 5100.00 a day against me.
Signed this . ✓ Si" day of / 20/2_ For clqzatmental use only
Permit Number _
7/ 7 " or " Map# Lot #
Signature of LX. • ermittee
',I/1'e - 6 , , amitkit.,-41etiea/44 74, jaei Jett
OO f kx:: ooff oa saut t ° Aftairs and 1 USillt:SS. Reottlat ion
14.;-'71,0 10 Park Paz Suite 5170
Bost °+n, Nlassachusetts 0
1lorne irnprovenient C0raractor Registration
t q str tort 131945
Type Ind wtdu ti
Expiration 10/13,20 1 4 Try 2.323 'C
STEVEN A. SILVERMAN
STEVEN SILVERMAN
268 FOMER RD,
SOUTHAMPTON, t 01073
lapdatr :4ddrr +x and return card. `lark rein n for chan ea
. ddrei% Renew 41 f:rtUPtosmen1 Lot (3rd
CA .
! t'eA <. 2`rr. Lit-twit or registration *and for India dul axe out)
Offner rrf t"�xaxamrr _' ffaar du aurxx Iterode t�xn
HOME IMPROVEMENT CONTRACTOR before the expiration date, if found return trr.
Rt�irat#c� 4�E Type
()frier of Consumer ,.ffairt and Dullness Regulation
=
16) Park Plaza ; Suite 1 1'11
Boston, MA 02110
STEVEN A SALVER !
STEVEN SILVERMAN
Sb ROB f
SOUTHAMPTON, `, 0101/ t ider+rtrz°mey Not 'satin walling xi nature
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of licensellolder : Stev_en Silverman_ 077279
License Number
268 Fomer !. =d, So t .ton MA 01073 6/21/1!#
Address Al
ihr 484 Expiration Date
� -7522
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Steven Silverman 131945
Company Name Registration Number
268 Fomer Road 10113 // _
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 X 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
t 1
• F,TcrioN 5. DESCRIPTION OF PROPOSE() WORK (check ;111 poolic*,11)
, New House ' L.'. Addition Ll Replacement Windows : Afteration(5)14 Roofinc n
Of Doors :.:
Accessory Bldg. .71 Demolition New •
New Signs " I Decks ; ) Siding r j Other
011 r ; ' rr :tre' ,11 C A V" , R ' lout_ tO 10 Ailliajyyl: Iry i.,‘) 1,/,(1,6 4., riltd Vood t (WI In 14 4
.:,i.,.. e•HR" trip htioro-411 _____ Yf- __ ___ No 6 .A,-,, irp, rt4v: of- Ye 's T?c rIc
;- %drrdtr,, ci:‘,.'kuvoll' ii -,11`,' 1,:;,:isrult
Flo , ".ttor,hee Pol. Snee:
6a. If New house and or addition to existing housing, complete the following: /
ii •a- ot ou . C'E 7 am 1,, Two ramtly
each '..sr ,1r,,t' '4 :111r1r;°F;'' ::,1' hatr,fcc"
.,- k t - :: ■ t',I2 0' .7e ,i:L.-,chee?
/
J H; G; rx.,- Sorrort loo ,1 nt=, .01ff tl siCI :xri :VI till I',ti t°,L,
t. "Ir'sro:i o' 'loot rtif I r tl: ', .' ' "cOdt Nu—Ur u' coch
■ a F Ce :.7,:or'r; ia ,.....„„,....___„,„., Milsr. ...ck. Efte C;_anol for 11 attactuad
:- ::I co /
• tk..1 w,11111 10 ot valt ..e:tuu,S? ieS "10 IS f.::)1S0 ..1;;C.:01 w:h: 100 yf , 1,,:;<,d; Yer, ...._No
t
:
of t,..rement (s! eelLar 1 :',elow °Inif..-rien
ou kfirp, c rDr-r1 to "d 0 Ez,u,lc.thp XI d ?C`WIR r Yei'', No
SITIIC , Ci....y SeweJ PI vc 00:;,1 (30'..y watf.A.f St*p y
•
SECTION 7a - OWNER AUTHORIZATION • TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• Cli v- r 4A 0 / 3 )4
, as ,Dwrier el t subset p ty
Th , S teven. „ Silverman, , Valley Home Improvement, Inc.
m„ i,!Ji-ti. - . "•11.;.'e RI VOI' i.ttliii(:•■?t,1,; 1) ihif, b,..,,1:0 11R :,,; acjpiic tic,,
.•,
Slifa:Jre of CikVier
— — „ - — - -- —
• Stemen_SibtermaA,Valley_Home_Improxement,_Inc.... , A. -,.17 fAu1nir171-1 APf-nt
hE.," j-:.T Ne ": ',"it.," .stiachivrts Dud infc.tr the bruK:Ar „p irrif:! .1re :rue dm' ilur,,,L.:rctte, ti 'he bt',,',. G cry
1 c'i.iccgc. rnc oclief
: - . .[2 Di `,.= ilr . .‘......Iii 0c1, 0' p:ri...,...,
Steven Silverman_ . , I/
,e
...._
:%.. le' 4.1,: r !
„...,,, ,/ „, / 2--
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) t'
# 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: l
IF YES: Was the permit recorded at t h e Registry of Deeds?
NO DON'T KN9W 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 aqy proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Department use only
---- - Ci ty of Northampton Status of ,ii:
B uilding Department Curb Cut /Dri
212 Main Street Sewer /Septic Avail city
�� 3 ZQ�Z Room 100 W er /Well Availability �"`, ,
N rthampton, MA 01060 11 • Sets of � cctural Plans :'
pEPT.OFBUILLANGIt,1a, "V! TWA- 1 587.1240 Fax 413- 587 -1272 Plot /Site P 4.* ` `
NORTHAMPTON, dA 01060
Other Speci � .,
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
2-0 2 (,ic 2 - I L) Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: pp Q
G hi V 1 ;4 )r) P ' � ) t'v'P/`- To & , a . 'E / L4 Alf , t j
N.' e (Print) Current MaiJigg dress: � �
Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Valle Home m•rov -'gent .1 P.O. Box 60627, Florence, MA 01062
Name (Print) � Current Mailing Address:
/ fi liffif � 584 -7522
Signature - I r Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (0 ) /JU (a) Building Permit Fee
2. Electrical 5 (�L) / (b) Estimated Total Cost of
/ L Construction from (6)
3. Plumbing r Building Permit Fee
J
4. Mechanical (HVAC)
5. Fire Protection � _
6. Total = (1 + 2 + 3 + 4 + 5) 7 / /50 Check Number ��y�r„-, ��' p� �i C, 5
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0616
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 41 MARK WARNER DR - 20 BRIDGE RD
MAP 16B PARCEL 001 041 ZONE SR/URA /RI/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
3a) `66
Fee Paid `�
Typeof Construction:_ RELOCATE BATHROOM DOOR,NEW VANITY & DEN FLOORING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 077279
3 sets of Plans / Plot Plan
THE FOLL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/'; 7/Z-
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
41 MARK WARNER DR - 20 BRIDGE RD BP- 2013 -0616
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16B - 001 CITY OF NORTHAMPTON
Lot: -041 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2013 -0616
Project # JS- 2013- 000997
Est. Cost: $7250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): Owner: SIMER CHRISTINE
Zoning: SR/URA /RI /WSP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 41 MARK WARNER DR - 20 BRIDGE RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON :12/10/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: RELOCATE BATHROOM DOOR,NEW VANITY &
DEN FLOORING
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 12/10/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner