30A-035 (3) � � �>$ssACETnsetts
m DEPARTMENT OF BUILDNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CON2ENSATION INSURANCE AFFIDAVIT
I, si I/�i�SI�I/ c �7��, �f�ZG �`� /�i�l %li•2/� ��%Z%Jl �
(IicenserJpermittee}
with a principal place of business/residence at:
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� ��.-.�✓��'� jL GrZI���'r%��`ir�,�Z��2�I (phone#) `� ��5 2
(6tSert/C1tY/S tP L1DS
do hereby certify, under the pains and penalties of perjury, that:
0 I am an employer providing the following worker's compensation coverage for my
employees worlang 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 Compazry/Policy Number) (]Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Compamy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shzd ifne==ry to include kdonnation pertaining to all contraaiors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner perform all the vork mysel'IE
NOTE:please be aware that winlo homzowa=who employ pecsora to do mamtmmot,constvetion-or ropairvork on a welling of
not MM then t niL+`t*.°E, �hv-^w r���:aw-or a :;�g osss�ar sr�t nif ih a am r;cy, coa, Yd io aye
r^ray��•w-.c�"Ok. c —r(.^f 7< f it ° f.. .�`. ..,.- i w.. iii"` k...w
"}•.� �..� ..... __� _i .»9�''.w.=.__�..y . .. .u:E e�m:i:is:J:p'z`.=1:;:u:i`�"y tl rri,..s...:.
legal status of an Moyer»der the Wort, a Co=pausatioa An`
I ccn .snd that a ropy of tlu,;r===m nu y be forwarded to tilt-ncpct-_r of y,,.6 ial A_---id=te o!no9 of Era smac:fb-the
-Vamge verification and tlzE:faiiare to s�COWM s under sectoa 25A of MGM,152 can lead to the ikon of criminal p.-aaiiies
coasL,ztingafafim-ofuptoSI,500.Oomdforim of up too=year and civd p=atties is tbz form of a Stop Wa L Otde•aad a
fine of 5100.00 a day egaLrd tar
lgzed ____day of ` �:�''i �i��/� Lam'I .1 r stn l—
�j Permit Number
I C�/Zrr'/�% , //,/ /�!�/',f�/: ✓/�'i I l�fa4 Lot#
ft at=e of Li PeriL&. , I
^
. .
' 5EC��� �' ��N�T������& �E����ES
;d#d - s
Expiration Darc
re Telep�one
Steve Sil-yeman 131945
Com
268 Pomer Road
Address Expiration Date
Southampton, YEA 01073 —T-.;ephone 584-7522
ON 10-WORKERS'COMPENSATION INSIJ RANCE AFFIDAVIT(M.G.L. c. 152, §25-
Workers Compensation Insurance affidavit r-nust be completed and submitted wit"i-I ths application. Failure to provid'e this affid'awt
will result in the denial of the issuance oil the b0ding permit,
11.. - Home Owner Exe
The current exemption for`homeu,mvrs' was extended wioc}uUe [one(l) or rw*(2)famUiex
and to allow such hmoeownpr to en��uo �d�d� f�hi�who�mnmpo��su (��oc.
as supen-isor.CNIR 780. Sixth Edition Section 108.3.5.1.
Definition of :Person(y)who own u parcel n[land ou�hichhei�shureuidcsorhnU�odsmreddc'oonhic6/h�,re
i.,. nrisintcn&-d`nb:` o one ur two f�-Ili7NrdneUinu�'auurhcd of-demchcdmmcn/nosaccesx"ryu`such use and/urfbn:
s�n�u�ry
!)L-
Such ^^bomoopncr"shall submit/othx Building Official, on a form ouocptab\ctothe Building Official.
responsible for all such work nerforined under Cite bujiidin2 pernift.
As actin- yoorprruen,eonrhe iob"i(r«/i|l6ee?uire60nmJmietolimc.dudnp,and upon
completion nf the work-for which thixpcunitisissued.
Also 6eaJvixed that with reference zoChapter 152(Wnrkmrs' Cnmpensation) and Chapter 153 (Liability of'Emy/nycom
Errip{my!�tu injuries not rcuubbng, in Deat h)of the MoxsochmmzsCienorul Le`:y Anootatc6. votj mav he liable Ou/persoo(d
you hiro to perfonn work for you ooderHhix pcnni|.
ThO Undersioned"homeowner"certifies and assunnes responsilbility for compliance with the State Buildin,-; Code, C;",juf
�o:bz���r�� Ordiuznccc. ��n~r ard )'ora| Zo,i/�� !/«��o�� c�,�c or\1ue*�huocnx�cncrz| l:n's �nnn��zod.
f 1
r-. IF 14ow house aii-d or addifiog to existhig hv_ using complete the following I
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SECTICN 71 -OWNER AUTHORMATI.ON < O aZ COM2PLETEM WHEW
:
OWNERS AGENT OR CONTR C:TCR AR:PUFS FOR BUILDING PEI:??`MIT
l �o
f € Stevenp,. Silver= .,Valley_I-€o�[cn_..Z p�c�v mea�t� _.Inc.
I
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"`.'0 I. � r [� `..P _�a.6IL`•tf[r i„_ ;-'GI„ ! 't`:�+f� �.�a411." (.�fC� �E::�:�cl6 �:til�.`f w_.tl..;. ..Fa. ,rl.;r .� sv!,..,i ��r�--, l't '.�kr t s� t�' E:t�t
Stever ilve an
maw
L ENTFORMATION MUST BE COMPLETED, m>° PERNET CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column 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?
i
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, ody of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit be or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on e property? YES NO
IF YES, describe s' e, type and location:
D. Are there a proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
Department use of ;j
City of Northampton Status o=;°ermit:
.� Building Department Curb Cut/Driveway Permit
® � 212 Blain Street Sewer/Septic.Availability_
Room 100 Wad r/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587.1240 Fax 413-587.1272 Piot/Site Piaris .
Other Specify.,
APPLICATION TO CONSTRUCT, ALTER., REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY Dlrt'ELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: is section to be completed by office
c Ma �6K Lot Unit
Zone Overlay District
Elm St. District CS District
SECTION 2- PROPERTY OWN'ERS H 1 P/AUTHORIZED AGENT
2.1 Owner of record:
-Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Ascent: Steven Silverman
i Vallev Rome .m-D ovelEma inc P.O. Bog' 6062'7 x_a'6^ren—e, TAP?+
Name(Pri �r Current Mlailing Address: e
o
584-7522
Signatbr Telephone
I SECT Oct S - EST!MATED CONSTRUCT€Oh! COSTS
w
to :, -SWT. ted Cesi(Ucllars) o be ufiiciai use Unit' j
completed by ermit applicant
1. Building UUC) (a) Building Permit Fee
f
2. Electrical (b) Estimated Total Cost of
000 Construction from (6)
3. Plumbing l 5e Building Permit Fee
I�l/
7-
4. Mechanical (NVAC)
ire Prc _i.J j I
6. Total =(l + 2 3 + 4 + 5) 31, 5-oo Check Number
This Sectkwi For Orrfcfal Use Only
l Building Permit Number: _ Date issued: __ I
i
i
Signature.
guidng Ccrr.mssioner/inspector ofuiidinr-s - at
File#BP-2014-1360
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 327 RIVERSIDE DR
MAP 30A PARCEL 035 001 ZONE URB(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
Typeof Construction: REMODEL KITCHEN
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
INFORM ION PRESENTED:
proved 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 clay
Si e o Building fficial 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.
327 RIVERSIDE DR BP-2014-1360
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-035 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-1360
Project# JS-2014-002291
Est.Cost: $39500.00
Fee: $237.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 2787.84 Owner: POPE LINDSAY
Zoning: URBS100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 327 RIVERSIDE DR
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.612312014 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL KITCHEN
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 6/23/2014 0:00:00 $237.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner