17A-291 o. o
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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