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31B-314
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GEOFFREY BURGESS 340 Riverside Drive, PO Box 60621, Northampton, MA 01062 TITLE: 2ND FLOOR BATH SCALE: DATE: Office Phone 413.584.1522 Fax 413.585.0820 DRAWN BY: SAS 3/4= 1' - 0" 12.19.2012 Find us on the web at : www.YalleyHomelmprovement.com . 1T1iAMp7, — •�� a !ixir Dorf NartII &nt4tr�t . ° *= B �+1 ;Y;,; S` 6 jeassacknsetta MIT t �_ `=' t:: DEPARTMENT OP BUILDflZO INSPECTIONS __ ` _ . 212 Main Street ' Municipal Building 7 0, m - • S Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, ,t/E1-$k[' ki i fJ - &7"7 1 v,17--/-i.1 i'x-e_ 1- 11 44Vs /1t--F!! %, L (license&permittce) with a principal place of business/residence at: 3 'o !e)d S fb 2 ./1/i/` / / f/a , -/ - 77,17/7,70/ 1 ; i'l f (phone #) 58 `f 7 " (strert/city!s',aLhip) 6/ O do hereby certify, under the pains and penalties of perjury, that: 1 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) ( ) Y 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) (attain additional sheet if necessary to include information pertaining to all contractors) ( ) 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 tremor' , coostructionor repair work on a dwelling of not more than three units in which the homeowner resides or on the ground appurtenant thereto are not generally considered to be employers under the worker's union Act (GL152,ss 1(5)), application by a homeowner for a license cc permit may evidence the legal status of an employer under the Works Compensation Ad. 1 understand that a copy of this statemeai may be forwerdod to the Department of ]ndush ill Aceideots' Oflioe of Insurance for the coverage verification and that failure to sense coverage tinder section 25A of MGL 152 can lead to the imposition of criminal penalties coosistiag of a fine of up to 51,500.00 and/or imprisonment of up to or year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day against tae. Signed this - / day of /' 20/4 For depatmmtsl use tasty /(/ / - ` - Permit Number Lot # # • . d LArL�` �1yL. Al-°' Ma Lot Signature ofL -Ze •ermittee SECTION 8 - CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Steye_l Silye an_ 077279 License Number 268 Fomer Roa Southampton, MA n1n71 6/21/1/ Address Expiration Date / � t 584 -7522 S ure Telephone 9. Registered Home Improvement Contractor; Not Applicable ❑ St even Silverman 131945 Company Name Registration Number 268 Fomer Road _,___ _2. 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 lift No 0 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 )cal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signatu / - -- • IXTION 5- Dr$CRIPTION Or PROPOSED Ws Ric (chock all apillicablP) [ , Now Hue LI Addition ca Replacement Windows L Atteratior ` Roofin n ' Or Doors :: Accessory Bldg. J Demolition° New Signs : I Decks ; j Siding [ ] Other . I Dev.7 on (•,;! Pr:: rvec Ato-K ?G 0\C Ci- C'e 3 /vi 8 ATH , N 0 c H A N OE TD EATe2-10{c ; , Nu , tit_ Ut crIA it At ,c.1.,1 - R P AIN) GE-) 1 ,:...1.,, :1' Is..tiiF., ht ) (ft.: '6 No :' r nf 'Ye..1+ :-t:iAtieu Narrtt(lytt ; A l'%11 RI si t;eit:rIlltrIt 't - 75 .9c, ' ikef pix-, 4t.tzt:hcc', Poi: S'leet 6a. If New house and or addition to existing housing. complete the following: .,)v,Ictir , C 7 arn ly TwO r artll'i b I\ :Irrtner il" tCO'z'S. 1 each 'ar tir,,t: %tifnn.e or tietNrcc.,T.F a:tachee?_ J F;;: !1 :t nt'lw ;owI,Jet ;o1 _ _ _ , :)1if-,..rvL,low, : , r.tc.tilsi t. 'V c of hetOkrig`'' 1 1 tl; tv,:mt. ta 'Nccdt Nar of o:ich F-,crEy Cc Cor ia M2scht26-, Ene-gy am:Dr:A f!....orm a:t A COt:C1 • -,ce.rAt ,,,.;:l.l viltici 10`j *:( ;#1" ?..et' 'es Nlo., Is C:A o,:trur 100 yi i 1 NT,trt ,'It t:,;osement .':;! celir 1 ':)(4 heine/ rinialet! 2J4 i k t'„I! to Idi rli cc f f;Dr•11 t 0 "dle 13(11',:n fig iinl d 20ninp. 1 ^31.":„. tat le ' . Ye:, No ' L Sic 7 .,1 . 'lk C:y Sewt Pr vti's,i-, ve' ,° ,31ty water Sop y ........ ....,__ SECTION 7a - OWNER AUTHORIZATION • TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT "eor7 ?el/eE S , as :.:1er ci t* sutly:ct vo;:erty litnnt17t Steven ,Silve rr.aan, Valley Home, Improvement, Inc . tc..t on rn 1,:c ;, ,JA - . j;,;t: to v..):,-, atlille: 'oy INS C; fop, , C'At KIPi1C,:11(1 , ., ..■.----°'-' _ Sig(' F.Jre or Owier • .S....texen,_ Silit.e.tMan, Valley Home Improvementi_Ing . , ;,,,,, '.. 1 1 dccr..rt ;hal: '. ti',..i,itcrric :..,.tict irlfotr u- the for ei.toirk; ziwi ,tre t•he or:d .i. 1,,, he •re-Alccce rric bchcf 3,1, _: Mc 7_: Z/ 1."..''lil tit“:.. Li' puri,,,..,' Steven Silve .41 _ .. "_ ,, C''' , , ,__ _ ____ m 1 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 1 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 KN• 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: .-i City of Northampton Department use only Status of I4 �t 4 Buildin Department Curb Cut /Drava Ftrrnit ti ` MAR 1 32813 g p y y 212 Main Street Seer /Septic'A4railabili y . Room 100 W r /W Avaa . -- 7u c ;N <s PECTIoNS Northam ton, MA 01060 T .Sets of ell il aural bility Plans N(.RTHFMPTON, mA 0-060 p phone 413- 587.1240 Fax 413- 587 -1272 ,6101 Site PI Other Spec � . ; r �w .3, 4 , '° APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: �j 0 / ,/t //'/ Map Lot Unit MA ✓ � f e -7 ,7')/ ` �,yf- 674669 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: (JZ /t /1 st /f/j7- `f (!i ©� — -- ' J ; 41/6 z 5 S Ili/ deli /' , /I 1 'If 3C' Name (Print) Current Mailing ddress :: /' /� Telephone r7` ? '" Z i 90 — ! 7 Si re 2.2 Authorized Agent: Steven Silverman Valley Home Improvem- , Inc. P.O. Box 60627, Florence, MA 01062 Name (Print) i ir Current Mailing Address: 584 -7522 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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 � /ti�� Q � Jog � �� 6. Total= (1 +2 +3 +4 +5) I !( Check Number V _( / i This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0822 APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522 PROPERTY LOCATION 15 PARK AVE MAP 31B PARCEL 314 000 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ? Fee Paid 3O / (� �7 [ (� eiel d (J , 4 0 Typeof Construction: REMODEL 3/4 BATH 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ORMATION PRESENTED: ro ved 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 0 I,- a litio % - lay y-/v-g Sig •: r; s :uilimg 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. 15 PARK AVE BP- 2013 -0822 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 314 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2013 -0822 Project # JS- 2013- 001415 Est. Cost: $18100.00 Fee: $108.60 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): Owner: BURGESS GEOFFREY V & CHRISTIAN A GUNDERMANN Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 15 PARK AVE Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584 -7522 Workers Compensation FLORENCEMA01062 ISSUED ON:3/15/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL 3/4 BATH 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 3/15/2013 0:00:00 $108.60 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner