36-225 re
The Commonwealth ofMassachusetts
Department of Industrial Accidents
t_
®use®I®flifesffglvdafts
r — 600 Washin -ton Street
Boston, Mass. 02111
' Workers' Compensation Insurance Affidavit
A �larant slifal ntation Ple;c'1'k "I'i gtl�y F
name:
location:
city nhnnc 9
r] I am a homeowner performing all work myself.
r[] I am a sole proprietor and have no one working in any capacity
® I am an employer providing workers' compensation for my employees working on this job.
com ariy n irrie Valley Home Improvement, Iric'. _
address: 340 Riverside Drive
citvi Northaatpton, MA ''01060 phone t, 413-584 7522'
insurance co.A. I.M. Mutual Ins .:` Co iolicvn<WMZ8005610 01 ?>2008i
I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
conlpan�,_:name: —
address:
city' phone tl:
insurance co poliev
company naine:
address: _
insurance co olicy 4
Wttttch sd>rtronsl sheet if uecessart
Failure to secure coverage 15 r—!nr under Section 23A f MC L 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as evell as civil penalties in the form ofa STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby certify under the pants and penalties of perjrary that the information provided above is true anrd correct.
Signature-
7_
Print name
._. -com —.�••-r�-r�=_--_T-^---�-m--P-�-¢•,�- '°-.=...--' .�_.,_.�.__'__y_ �..�'�s�, '�"''
official use onl} do not write in this area to be completed by city or to:an official
city or town: permit/licciise d FIBuilding Department
k' OLicensing Board j..
i.
s1 0 check if immediate response is required OSelectmen's Office i
E]Health Department
r--= contact person: phone#; MOther
J 0
f N �
N } N ^
V) 4, c0 N -
0 . U o
J p H Lt
W
tt Q. (h _
7
(n Z oCO N C() C,)
p `_f. C 0) Q 00 1 I
m
U W D i Z
OU x7
F---q X ca
4 a Q'
c O C7
U Q W _
O
WO x ra 3 �a�
rm .Y > u- v m
IW— coo a `\ `�' m °�. v
0
<
co M
co N 4s, Z
Ln
v o
C)
CL n
O y
O V 0
V,
A
N
CD
� otryc C'
S O A
.: m A o 0
CL
_y
aQ• w o ,,,,, a
C = O•
O G a
lb c
C ° c
a y
y O fD
I
`
.1 Vicensed Construction Supervisor: Not Applicable 171
Name of License Holder � Steven Silve-rman------ 077279
Address Expiration Date
IF
Signature Telephone
9. Rezistered Home ImptovernenLCgritractor. Not Applicable 0
Steven Silverm n_-_ 131945
Conip-4py,Name Registration N��ber
Address Expiration Date
Southamp on, 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 affi 0-1
will result in the denial of the issuance ol the building permit.
Signed Affidavit Attached Yes....... 20 No...... 0
'
11. - Home Owner Excm
The current exemption for'1xnnoowncs^ was extended to iudodo Owner-occupied [one(|) or two(2) 1-ami|ies
and no allow such homoowoerto engage au individual for hire who does not possess ulicense, provided that the owner acts
as supervisor.' Definition of Homeowner: Person(s)who own oparcel [ u kind oo which hc,"sh o resides or intends to reside, which there
or is intended to be, a one or two family dwelling.attached or detached structures accessory to Such use and/or farin
structures.
Such^homcuxmcr''shall submit to the Building Official,oou form acceptable/o the uuvuu," Official,
responsible��ad��� your presence on the job site Nvill be required from time to time, during and upon
completion uf the work for which thinpoonit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter \5] (Liability of Employers tu
Employees for injuries not resulting in Death)of the NlusuachuaeusGrnnra| Luna/\uno«atod,vou niav be liable hurpernoo(s)
you hire N perform work for you under this permit.
The undersi-ned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton 0rJinuuoox, State and Local Zooin- Laws and State o[Massachusetts General Laws Annotated.
}
rC�T t P • DESCRIPTION OF PROPOSED WORK_C hr r_k i!11 ,y?
F
Ntry Ilc.usu :_ Addition ! Replacement Windows A.'tet ation(s) t j Roofing 17
of Doors
AcCESsory bldg. 2 Dernolitio.'D Neer Signs Decks ? ) Siding Other f
`d �'+_'.i� 1`i .lt'i '.'� "f":�(.' .t',ti r"�4"1...... ��i.� 1�•'.� Ki �/l� F�' �v:f..�
Yw.;
j•::t'
"ID
Iij. If New house and or addition to existing housin;g,_�omplete tho following:
r
_.� I�'.t. ,.,C �iP.It.,� � f^,o",� ,,,=-C 11�y � �;�`:�I•d�t l'p' 0",nf
to➢`"uy R;t'tk: 'vt1' .,., ^,.-t�ft.r..,,.,r §
�. �+ lii"',.„J Ci' 1'Yt; 1 �C?"� i t -I - :.. •. ,it a�'(,'+,I t.+.,'+C, _ _,. f'w t,l'.=li:. R,1� !-J.Ifskl
4•
#i
I
?00 3
yl. 'ic., �l.a i f.. 9' c; i
+ 1;,l;?•t .a! �, i9'.r:'S','4 G:hi E. t..,I l:'�d I,".r("i P'�!t'.'�:.`S w7 `Ia 1 !�4'.i� �..+.j('G
i
s
+ � t rye kt R;S�•• fi t � � �•! �
,as•it t„ ,<. I,tI'!„r9s,�, i,+,�. ,•.,I �, r �;.1,7t1t. .,. Y�. 3�a��
htRr k t ;v
9. . -
Y SECTION 7a . OWNER AUTHORIZATION .TO 13E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i s.k.;+ -Itj
R
^Steven Silverman, Valley ._Home ,Improvement, Inc.
At.,. a , a'1 - t 'k„ .. .. .'«l9,•t• tt� ,._19� .-tttDat, o:r�A� 1;tR5 1 .t Ili, ,r., �,9i .�.7l�iR;,.�2it'>'•t
J
{'1•_."_'1.,'`,” r't_ dCt� _3. ^�'�. "s.,1 ltan�. 1'.i Aid Ia;I+"ilr>.iyp ;jID o; thy, "Al'w 3 ;,! Iry
Steven Silve -an___._.._ Jj
4 +�I t .w ;!
� s
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/Finding ever been issued for/on the site?
NO DON'T KNOW 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 arty proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
3t)
Department use only
City of Northampton Status of Permit:
Building Department CurbCut/Driveway Permit
212 Main Street Sewer/SepticAvailabiity
Room 100 `hater/Well Availability
Northampton, MA 01060 Tvio�Sets of Structural Plan's
phone 413-587.1240 Fax 413-587-1272 Plot/Site PI
54
Other Spectify�;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:
Map Lot Unit
Zone _Overlay District
Elm St. District. CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: lk:�/Ll`" Z-. T<-4--
9
Name(Print) / Current Mailing Address:
Telephone s
Sigri, ure ✓ �� ��
2.2' qth
orized Agent: Steven Silverman
Valley Home Improvement. c
P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
_584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by ermit applicant
1. Building y� 060 (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 =(I +2 + 3 +4 + 5) o t 6) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued: - ---
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2009-0565
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0565
Project# JS-2009-000806
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 131945
Lot Size(sg. ft.): 63162.00 Owner: KATZ JAMES K&GERI A KLEINMAN
Zoning: SR(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 60 WINTERBERRY LN
Applicant Address: Phone: Insurance:
P O Box 60627 (413)584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.121312008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 6 REPLACEMENT WINDOWS
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 12/3/2008 0:00:00 $35.0024985
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
60 WINTERBERRY LN BP-2009-0565
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-225 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ry: BUILDING PERMIT
Permit# BP-2009-0565
Proiect# JS-2009-000806
Est.Cost: 5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use GroU2: VALLEY HOME IMPROVEMENT INC 131945
Lot Size,sq. ft.): 63162.00 Owner: KATZ JAMES K&GERI A KLEINMAN
Zoning: SR( 00)//WSPI1 Applicant: VALLEY HOME IMPROVEMENT INC
4T. 60 VV1N1Ti=rN)r-9.Rv s N
Applicant Address: — �— —A—one: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:121312008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 6 REPLACEMENT WINDOWS
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: floue# Foundation:
Drnve*ay Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 01. Insulation:
Final: Smoke: Final: ok6-,12.7107 Geur�
THIS PERMIT MAYBE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT ON OF
ANY OF ITS RULES AND REGULATIONS. -�
t✓D 04r4,6T1 o 11' / io
Certificate of C2ccert - ( Signature:
FeeTwpe• Date Paid. Amount
Building 12/3/2008 0:00:00 $35.0024985
212 Main Street, Phone(413)587-1240,Fax: (413)587-127?
Building Commissioner-Anthony Patillo