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17A-291 o. o � " ((r� a B �1a54RC1lttBrtt4 � DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WOREER'S COMPENSATION INSURANCE AFFIDAVIT ht m f (licenstel�littee) with a principal place of business/residence at: -02 do (stxxt~t/citylstatei-ri�- do hereby certify, under the pains and penalties of perjury, that: 0 1 am an employer providing the following worker's compensation coverage for my employees working on this job: 111-10If3DO< 1` Zl (Insurance Company) .(Policy Number) (Expiration Date) ( ) 1 am a sale proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies:. (Name of Contractor) (lnm ance Company/Policy Numbcr) (Expiration Date) (Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date) (Name of Contractor) anstrrance Company/Policy Number) (Expiration Date) (Name of Contractor) ansu=ce Company/policy Number) (Expiration Date) (attar,addidoaal shed ifnecrssary to i wludc iafvrmaiion pstaiaiag to all coahlaors) ( ) I am a sole proprietor and have no one working for me. ( } I am a home owner performing all the work myse f. NOTE:please be aware that while hoa=w=m who employ p=o=to do o-Z-JCti0Q or repair work oa a dwelling of not more than th=tntiu is which tree hoteax-mtr rtsid:s z m tSe gvuids grva teuaat t veto ere nc<gran. dly c=klved to l.- is itYirr�tm5 s:or' "s '=Ad ss l(�j},r ppucanan by a homcow=for a lice a Path mey eaid=n:t`-, legal etatua of an employer under the WorkAes Compensation AcL I undr_catsad that a copy of this zb ti ms may be forwarded to the Dtvartmmt aff I —sHal A=dea&Otnoe of 1mumnes for the =v=.p verificatica sad that failure to se=re=emp under section 25A of MGL 152 can lead to the'imposhiaa of crima Penalties coasistiag of a fine ofup to 51,500.00 and(or of up too=year and civil permltie,in the form of a Stop Work Or+w and a of's 104.00 a dwy sgie!m-. 1 Slgned t day Of 4' 1^L Lam/!;' for dq=t=1ts1 use only Permit Number Lot A zo L t#fe/i. ✓ ,i J RRap# ± Iric lPermid-- SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable 13 Name of License Holder : Steven Silverman _, __. 077279 License Number 1 268 Fomer Road, MA 01073 6/21/1 ` f Address Expiration Date t 584-7522 Sig ature Telephone ' i i 9. Re isfer6d 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 the application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... IM No...... ❑ 11. -.Dome Oymer Exemotio> The current exemption for"homeoww-ners"was extended to include Owner-occuni€;d Dweilin s of one(1) or twao(2) families and to allow such homeowner to engagre an individual for hire who does not possess a license, provided that the owner acts as superv.isor.CNIR.750, Sixth Edition Section 105.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he,she resides or intends to reside,on wvhich there is, or Is interaded to be, a one or two farnily dwelling,auached or detached structures accessory Ito such use arid;`or farm SLrUci.u1'GS. A s4cY`si1 who cciristyaelks a"Gre one. S t1.0-','o-r"cre0!? S}I`11 rof he rof*3ifierect }$ �iy�etFtZrE'S1f R" Such"lromeow rler"shall subinit 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 Hermit. As acting Construction St.,pen4soc your presence on the job site ww!iIl 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 Emnlowers•to Eirployees for injuries riot resulting in Death) of the 'Aassachusetts General Laws ,nnotated. you talav be Hable for Person(s) ou[lire to perform work for you under this permit. 1'he undersigned"homeowner"certifies and assumes resprinsibility for coniphance with the Staite Building Code,City of Northai tpton On in-antes, Sia,e and L,ocn! Zoning; Law,,, ?nd State of Nfassachuse—as Gcntl:_Ill Taws Annot tcd. Homeowner Signature ' - --- ---~---- --' — - - - --- --- - - ' Nr« Hoo`L- AediUon Ll | Replecemen{ 0;cdm*s Ale RaKing | Or Door NOW If New house and or addition to eXistin.g,,housing...conip,i.ete the followIng., WOW Wasma gam. OWNERS AGENT OR CONTRA.CTCR APPLIES FOR BUILDING PERWjIT Ief as 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:7i Rear J Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved arkin #of Parking Spa ces Fill: volume&Location A. Has a Special Permit/Variance/ inding ever been issued for/on the site? NO DON'T KNO YES IF YES, date issued: IF YES: Was the permit record at the Registry of Deeds? NO DON' KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contai a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a ermit been or need to be obtained from the Conservation Commission? Needs to be btained 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: f i Department use only Ci;t of Northampton Status of Permit: Rlrl ding Department Curb Cut/Driveway.0errnit � 2 2 Main Street Sewer/Sepiic Availab Pity t'OS Room 100 Wager/Well Availability Warffia`mpton, MA 01060 TwoSets of Structural Plans ' °-" phone 413.587.1240 Fax 413-587.1272 PlotSite Pit Other Specify " -, y , 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _Name rint) Current Maili Addr s Telephone Si nature 2.2 Authorized Agent: Steven Silverman Valley some improvement. P.O. Pox 60627, Florence MA 01062 Name(Print Current Mailing Address:/)" 584-7522 Signat r Telephone SECTI^t� 2 - EST!MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be O ficiai Use uniy i completed by ermit a olicant 1. Building j goo (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from (6) 13. Plumbing , Building Permit Fee 4. l0echanica!(HVAC) 5. Fire Protection I l 6 Total = (1 + 2 + 3 + + 5) 7 (<�[�(� Check Number 30 f f This Section For Official Use Only I Building Permit Number: Date issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0937 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522 PROPERTY LOCATION 78 HILLCREST DR MAP 17A PARCEL 291 001 ZONE URA(100Z THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: ADD SIDE AWNING WINDOW&REPLACE BATH FLOOR FROM WATER DAMAGE 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 WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN O ATIO SENTED: 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 D, oli ' lay Sig of Buil mg ficial 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. 78 HILLCREST DR BP-2014-0937 GIs#: COMMONWEALTH OF MASSACHUSETTS MapBlock: 17A-291 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-2014-0937 Project# JS-2014-001620 Est.Cost: $2600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 21257.28 Owner: KIRCHNER BARBARA K&RUTHERFORD H PLATT TRUSTEE Zoning URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 78 HILLCREST DR Applicant Address: Phone: Insurance: P O BOX 60627 (413)584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:311112014 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD SIDE AWNING WINDOW & REPLACE BATH FLOOR FROM WATER DAMAGE 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 3/11/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner