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16B-001 (3) • o4 gttAMp1 0 • s A 4 l i r± xaf Nz rfli &ntpt.an _ ** ..__,_:. . 0 i B lassarimsetts ` �'� 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