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al,- DEPARTMENT OF BUILDDZG INSPECTIONS =__�i=
212 Main Street • Municipal Building
Northampton, Mass. 01060 `'��
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, .5.1" /e )/i_ t///nf7r/, Ofi , /t-Om i %i/✓ vsft i4T,..2?tC,.
' (li > ttee)
with a principal place of business/residence at:
.el/' i..6�`: ..s_/i. ,,,A-2 -77---7/-7,,,;-w/.,--//-7.:1,/ 7,4 (phone#) ZV.-7 5 72.—
(strmt/cityIst t.zip
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:
(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)
(mot additional sheet if necenaxy to include information pertaining to all era)
( ) 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 pen=to do maintenance,construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenantbexeto are not gully considered to be
employers under the worker's compensation Act(GL152,,s3 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worlce's Compensation Acs_
I understand that a copy of this statement may be forwarded to the Department of Industrial Ac ide rts'Office of insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lcsd to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fun of S100.00 a day against me.
Slgned�ls 1 _jr day of t'C;Jire ' Y\ z-,f For use r
I Permit Number
A// r./�isI'//v' ; r, /'' /r° J
Map ,Lot#
ignature of Li•... -- `ermittee '
•
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
hani,e of License H,older : Steven Silverman_ 077279 ________]
License Number
268 Fomer Road, outhamptan, 12A 01073 6/21/1_______ --- ----1-
Addres Expiration Date
/ik 584-7522__.._ {
Sign ogre Telephone
9. Registered home improvement Not Applicable ❑provement Contrac#arc K'.
S t even i lve roman.___-. _ _131945 {
Company Name Registration Number `
268 Fomer Road 10/.13//
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 SI No ❑ 1
1.1. - 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 tattoo
structures. A person who constructs more than one home in a two-year period shall not be considered a nomeowner.
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,Cite of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
:7cTICN DESCRtPTION OF PROPOSED WORK (chtck tvphobis)
N 'N FiCL Lraz "%edition J Repla:ceinent Wirdows A.tei-ition(0-6L Roofing I-
I Or Doors
Accessory Bldg. Demoliticy New Signs Decks 1 Siding : Other
73: vv. "r -Run, )1_ hi Sr. IFalk'J,41 (101 kir/Spy- fl
c Asie 24,v 0- di_ -FAArml
N.(
N,i-ret.s.ct°
izcd trt
611. If New house and or addition to existing housing,sornplete the following:
:-,ttrt)
t
, I t•
r ■,;" 4K+,', ;
*. 1:,;7•
cc : ci r.L0
t i 1 _ N C.:)11F.ir t :0C yi •
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' **s" ". ''.■=7 tf,r-ri to t.t,r t4i...1t!tict
ic C ,1„77::::,i; wt.::: y
SECTION 7a • OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-f. 1Ctr\A _Kek.n\i0A,V rtA)4---t n't Rc),
Steven Silverman, Valley Home Improvement, Inc.
rr * .11 .1,11 PO, !';.,.t .':II;11:":
0' C
/ Steven Silverman, Valley_Home—Inproirement,_Inc...
c" teKlw ;r: ttt% 1:t Ift; Lr t:
Steven Silvenman_
14-
7„...i,: /d/3//3
,
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/Fine ng ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recordrd at the Registry of Deeds?
NO DO KNOW YES
IF YES: enter Boot Page and/or Document #
B. Does the site co9/ain a brook, body of water or wetlands? NO DON'T KNOW
YES /
IF YES, h a permit been or need to be obtained from the Conservation Commission?
Needs tote obtained Obtained , Date Issued:
/
C. Do any Signs exist on the property? YES NO
iF YES, describe size, type and location:
D. Are there arty proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
i
.__ _,
DDepartment use only
City of Northampton Status of Permit:
NOV a ?OD ' uilding Department ,Cut/Driveway Permit
I 212 Main Street Sewer/Septic Availability
Electric. P_ i'''r,s Room 100 W er/Well Availability .,:'.
Ncr"` ` flurthampton, MA 01060 Twin Sets of Structural Plans
t�
phone 413-587-1240 Fax 413-587-1272 plot!' PI �� ,.. �,
Other Specify k'
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:
2(1 (CLvd 1 n Ur i / et"i/ Map Lot Unit
Zone Overlay District
Elm St.District_ CB District _
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'bak)ta �trz 1O1A k- + Kris-J-11-v_ !osS 2O9 CaAdry,4,/ 661Ji R0/09c( /71c oId 6z
Name(Print Current Mailing Address:
, (r' 1-ll - 297- lSS"�
Telephone
Signature
2.2 Authorized Agent: Steven Silverman
Valle Home Improveme, t, Inc. P.O. Box 60627, Florence, MA 01062
Name(Pri Current Mailing Address:
Lath ', 1 J /144— 584-7522
Signature Telephone
I SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only f
completed by permit applicant
1. Building I U r1r Cri,i0 I (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) d 0 01/0 Check Number 3/ g321 t$(P 0
This Section For Official Use Only
Building Permit Number: Date issued:
Signature: __
Date
Building Commissioner/Inspector of Buildings —
File#BP-2014-0577
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 209 CARDINAL WAY
MAP 36 PARCEL 319 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ` /
Fee Paid /gg J7 66
Typeof Construction: REPLACE WATER DAMAGED KITCH/LAUNDRY ROOM FLOOR
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
INFWrATION PRESENTED:
Approved 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
410K.
I I '•;op,n Delay
_,,i101° 1/11.ir fillI 7/ 3.".-/
Sign of Buildin: Of icial 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.
209 CARDINAL WAY BP-2014-0577
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-319 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-0577
Project# JS-2014-000965
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 19209.96 Owner: REINHART DAVID W&KRISTINE
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 209 CARDINAL WAY
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:11/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE WATER DAMAGED KITCH/LAUNDRY
ROOM FLOOR
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 11/7/2013 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner