43-074 (2) BP- 2011 -0627
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 042A)
Category: BUILDING PERMIT
Permit BP- 2011 -0627
Project # JS- 2011- 001012
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 17206.20 Owner: HAYES JOHN C & GAIL A
Zoning: SR(100)//WSP II Applicant: VALLEY HOME IMPROVEMENT INC
AT. 128 DUNPHY DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :1/13/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- REMODEL BATHROOM
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 1/13/20110:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0627
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 128 DUNPHY DR
MAP 43 PARCEL 074 001 ZONE SRO 00) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REMODEL BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
Demolition Delay
C, / /� ILI?
Signature of Building Official 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.
Department use oniv
I 0 \� City of Northampton #..tatus of Permit:
`Juilciing Department Curti Cut/Driveway Permit _
Jam 212 Main Street Sewer /Septic availability _
doom 100 Water/Well Avai'ability _
Northampton, MA 01060 Two Sets of Structural Plans _
s
phone 413 - 587 -124-0 Fax 413.5871272 Plot /Site Plans l
Other Specify ;
AP TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i SECT ION 1 - SITE INFORMATION
1.1 Proaerty. A ddress : This section to be completed by office
�0 �f^�✓
Map - Lot JJnit - --_-
Zone District
1 '
El m St. District __ -- . _ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZE AGENT
l 2.1 Ow of _ Record :
l � I
l� CC
n } - -- Current M Address: �l Telepr:,ne
2.2 Auth Age nt: Nelson Shifflett
Va lley _H ome I I nc, P.O. Box 6 Flor KA _01062
i 584 -7522
�!ur.r Te.cpf�aae
L SECTION 3_- E CONST CO S�CS
.... --- - ---
Est ma Cost (F) Ilarst tc tt� Use
c ruleled by perm l a Drill a- jj
_. Buiiding 1 J (u) Building Fern�'t Fee
I
O
C:ectr r.31 I �D J . ;) Estimated Total Cost of
Construction from (u )
m Building Permit Fee
4. klecita nic&d (I i`.'AC)
f
ber
}
Th Sectior, For Official Use OWY - .-
!I -irg ermi� C\ !mb ra._.. - -- -- [Date l.aucc ;:.. - -- - - -- —
i
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
p arking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO y 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:
v
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:
i 1 Ct'2 - s.:°.Df SMF f ION OF . PROPOSED D t "CORK fry v :a:
Cpl+ vw IIf:t_: >a :_: ?',Chit. I m.1 Rt�l2t�ftte. t 4 "6c JcwF, A.R�r
I j
, CCE: ' SidP_ t'CYi Signs I L)ecP',- «ici g
f
....r �, -.+.. ...m« e.. ..
-----------
6.. {t A1e Fa; W 110USQ acid or addition to xi, ttttg {7 r si ri complete e the w f {lo �•.� €ri�s:
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: -.�: iP' :.":.-.. :;,;� - ..t ^t' .a,,'.: • t � ..C6r ._ '':. a.,
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CT CVi 7,., a O- Viflrri AU T 6 0MZA ON - TO CIE C0f PL CTC Vi'AL14 6{
OWNFPS, r 4" 'T f,)R I.,d EMR, .;TOR A^?t TS FOP UR NG P6'n�w *li 1
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Nelson V v r
S cflett, �l� Horne
Valley rlprc� ernen , Inc.
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Nel3on__Sl � flett, Val'. ey. _Home_ Impr_oyeznent, ._Inc •
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Nelson. Shi 4 -
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SECTION 8 - CONSTRUCTION SERVICES
Valley Home Improvement, Inc. L�consc,
340 Riverside Pri- ampton, MA 010,60.
Fxp'rEa!o Date
lelephone
Re gistered. �
- mprovement Contractor:
Valley -Home Improvemen-t--Inc------- 105543
__Name Roryi Lion Nurnbe.r
340 Riverside Drive 7/17/
North ton, MA 01060 Te�'ophorie 584-7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
1 VvIorkers Compensatio: Insurance affidavit must be completed and submittcd - with th',s appkcation. Failure to providcthis aficav,t
1
l'li,mri was uumdod/oinclude |'ooc(}) or o,y(2>611113riiics
and to oUm,such hmnconnexu,on"o'-'c un individual F hire who does not pnseyzo |iccn`c.
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of : 9cnoo (S) who own x yumo| n[|znd on rhich h��sho xskjcx or {u|cods to nsidc, on v6ich dhso '
i�.orisintcodoJ/uhu.00nournxo6mUyJwrUin
mmc1ocs. A person %Nlio constructs more than one hoine ju a lvto t per:
Such ^humcomncr' xhnU subinitm the 8oiNino Official, oox Corm acceptable, |othe 005ciu
r"ponsible for ailstich 8�ork performed under the building permit.
Asactim- Constructioii Sunervisor your presence oil thejubsite will be required fi
c nf the work for which this permit isissued.
Also hc advised that with ofieoucomChuptor 152) (\Vorko,s'("ompcnsnzi011) and Chapter 153(LiuhUxyof6mpk. to
1,111ploycns§r iojuricc not resulting in Deat ufthe >4uuuckvucnsGcurm| Lans Annotated. you may lie liable /"or nc,snn(,}
yoo h(ru �o pu�/�on �o�t /�ryou uu�c��hispu�ad�
The uudersi-oed '1hunocomio''cerdflczund nyaime ospox»ibi|ig/Jbrcon p|ioocx with 1ho 8{a»: Boi|din� rodc. o[
Mmt 0rJinanccs, State and Loca|Ionin- Laws arid Stale oF\4uaodiuscnxGeneral Laws Annotated.
L�2 ( L al
Office of Consumer Affairs & Business Regulation a
=� e License or registration valid for individul use.only ,
n HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Registration: 105543 Type: Office of Consumer Affairs and Business Regulation
Expiration: 7/- 17/2012 Private Corporation
10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT - INC.
Nelson Shifflelt = I
340 RiversideDr 0 " i l - 1 Northampton, MA 01060 i --
Undersecretary N without signature
L ic_nSe: ,S 60300
NELSON A SHIFFLE T T i
340 RIVERSIDE DR PBX60627 �
FLORENCE, MA 01062
9/2222012
(urnnii >�in;= +'� fr 2383
ti' ti
� t y.asSRrlllt5Gtt8
DEPARTMENT OF BUILDrNG I.NSPECTIONS
212 Main Street ` Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION RiSURANCE AFFIDAVIT
(licenserlpermittee}
with a principal place of business/residence at:
/a,.r,..... ; M. (phone#)
(St f/C1tY/-.Ft 'Zip) 4` Ll
do hereby certify, under the pains and penalties of perjury, that:
W I am an employer providing the following worker's compensation coverage for my
employees workng on this job:
�
(Insurance: Company) (Policy Number) (Expiration Daze)
(} 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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Dafe)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) gnsu.ran Company/Policy Number) (Expiration Date)
(attach a.dditi=al slits ifnecsssary to include information psmioing to all ooatradors)
(} 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 hameown= who employ perxona to do =tat -„a suction or repair work on a dvvclling of
not more than three units is which the homeowner rides or oa the g =ids appurtenant thasso are not Szo=lly coandered to be
employees under the worker's . O=p=s4on Act (GL152,ss1(5)} application by a homeow= for a lime or petmit may evidence the
legal status of an employer under the WOri -o's Comoca&atioa A
I u d rsd that a c Py of thin 'tat" may be fcawrardsrl to the Dips tit of la.dilstxi d Accid=& Offioo of Inwarance for the
coverage vmifi=oa and that failure to secure oo reti under section 25 A of MGL 152 can lead to the iatpo oa of criminal penalties
consisting of a fme of up to $ 1,SOO.00 and(or irap o f up to ooe ytw and civil praaltia in the form of a Stop Work Order and a
fine of 5100.00 a day tg irs mw
Signed this M day of i e —
C "I For dqp&rtmtatal use only
t - ' ` ✓ I Permit Number
6i9 taatct� of L Permittee Map# Lot
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