16A-020 (2) 1 - SE'C'lON 8 - CONSTRUCTION SERVICES
,1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Nelson Shifflett 060300
Valley Home Improvement, Inc. icensc Numbe•-
j 320 Riverside Drive 9/02
Aci -fires . i Exi v itioa Date
Northampton, MA 01060
S °cna f _I re relepnone
584 -7522
Registered Homo, improvement Contractor: Not Applicable
Valley Home Improvement Inc. 105543
Company Name Registratic , Number
320 Riverside Drive 7 /17/02
Address Fxoirat on Date
Northapton, MA 01060 Telephone 584 -7522
t •
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Nor.< r s Compensation Insurance rance affidavit trust be completed and submitted with this application. Failure to provide this affidavit
. +:Ili result in the denial of the issuance of the building permit.
Signed ,Affidavit Attached Yes No 0
l 1. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) fanlilicti
and to allow such homeowner to engage an individual for hire ‘vho does not possess a license. provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on, which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use anti; or farm
structures. r person who constructs more than one home m a two -year period shall not be considered a homeowner.
Such "homeowner' shall submit 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.
A s acting Construction Supervisor your presence on the job site will be required from time to time.. during and upon
completion of the work for which this permit is issued.
Also he advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability. of Employers to
kmployees for injuries not resulting in Beath) of the Massachusetts General Laws Annotated, you may he liable for persons
yon hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building (.'ode_ City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
l lonicowner Signature
.
�1`rw t'¢ x 3esClFttSttts .
� f� .,_
- " u } DEPARTMENT OF I.iuILorNG INSPECTIONS ' `'-
212 Main ;Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CUN£PENSA'I ON INSURANCE AFFIDAVIT
1, NN'o l son A . .hifi tt l to l ley dome T1nprovement , Inc . ,
(Iiccuser/pernaiuee)
with a principal place ofbusiziess/residence at
azq Fxive i de 1 )rive, - Nortti ainpton, MA 01060 (?hone,) a13) 584 -7522
(streY- t/cctyfs -=t
do hereby certify, under the pains and penalties of penury, that:
n 1 am an employer providing the following worker's compensation coverage for my
employees working on this ob:
American interriation,al Companies We 6554540 00_ 02/01/2002
(Insurance Company) (Polies Ntunber) (Expiration Date)
() 1 am a sole proprietor, general contractor or homeowner (circle one) and`laave h
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Conipany/Policy Number) Y(Eatpiratiou Date)
(Name of Contractor) (Insurance CompauyiPolicy Number) (Expiration Date)
(Name of Contractor) (basurance Company/Policy Nuunber) .., (Expiration Date)
(Name of Contractor) (Insurance Couzpany/Polic) Number) (Expiration Date)
(auaih additional dot if n•..•" y to include iafot-ination pctaining to all coat:actors)
( ) 1 am a sole proprietor and have no one working for me.
( ) f am a home owner performing alt the work myself
NOT: please be aware that while homeowners who employ persons to do m•rotrn +t•n, construction or reisair work on a dwelling of
not t than throe units in which the hocueowtsrr resides or an the grounds appurtenant thee-tits arc cot generally ooasider■d to be
eusploYeta under tha worker's 0arnpezcsaricas Act (GL152,ss 1(5)), pliestion by a hotnuswner far a lionise et permit may evidcncc the
le-gal stsisu of as employer under th a W orls s Compq>s*tion A,d
1 understand that a copy of this staterneast rely ha forvvwrded to the DepartmaoQ of Industrial Aecidart:• Office of Iusur+woe for tbs
sovetxge vaiftcatiosi and that failure to steaare coverage under-scaiou 25A of MG3L 152 can lcsdto the imposition of criminal penalties
consist ng oil! fine- of up to si.5fl0:00 and/or ofup to ono yrnr and civil penalties in the foini of a Stop Work Oder wad a
firm 0(3100.00 a day against six
Signed this r j clay of iVal! : 2001 For e iv s salattsai toe) eel)
/ r Permit Number
..�.t./ , A �/le d ?Vial _ Lot # ' _
Signahrce Of Li... i • Cans 1
I .,
'ECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)M Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ , ,t New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: /,6U - s46td(s. d ill PAN,/ 5041 argeowi AL." FM( ("I
Alteration of existing bedroom Yes Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes ' No
Plans Attached Roll 0 D. Sheet Z! .rffnti Anzinc,it / f A / A
of to . he io arld of atiditio tolo ekistitith "it sing., complet4lhe fallowin :
a. Use of building : One Family v Two Family Other
b. Number of rooms in each family unit: 5 Number of Bathrooms .)
c. Is there a garage attached? y /
d. Proposed Square footage of new construction. Ai S^ti' Dimensions
e. Number of stories?
f. Method of heating? /t)/ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
I . Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION' - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1/1i c» y 7-- , as Owner of the subject property
hereby au orize �lU /� OA - ' � t o / Atli �s/AA to act on
my be , i • all matters r lative to work authorized by this bading permit ap lication.
Signat e of Owner Date
1, Al 0A S1' rot-
f /qtr , as Owner /Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
121 4, eI /D,- I S J
Signature of Own • r Agent Date
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 /(�
4444���"""" L
Frontage
Setbacks Front \ / 6
Side L: . G • R:
Rear
Building Height c�
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
P'. •
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO t/ 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 t/
IF YES, describe size, type and location: /U
L , D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
r . e*,
r
( " ' � '
fi r - 3 �1 �^': � t, � e� .,
City I N rthampton . us offP ,
,,,8tiild no apartment u - Cu /Dr _ - e,' /1 t � 5�, ,
�' 21 in Street r /;ep .a
L_ _ oom 100 r /W. ' -,� � �
'�26ff�t�npto 1, MA 01060 W ets� ' I
phone 41��7 1210 Fax 413- 587 -1272 t� y a .� Y
s. 1i«'•U .,3 p a r t to 9 4 --
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
4i 7 �Gl )/9 •/ 4 Map / Lot h Unit c
/b 0 1- " 1/ , y1 �� Zon r ®./ PI44 , f�'�erlay District
Elm St. District CB District_
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: L/93 (/}!/!fC/ //4f — .36y Jj/J t5:6 -i 3
EL '/1 ra A `(A i ivZr ,4p/ 7/f1 <S ®N .;) PJC( %d ec0 0c9i?
Name P ' ) Current Mailing Ad
�_:- fl � GY�7 Telephone ��� � ����
Signature
2.2 Authorized Agent: Jf9/ /e � y ,Y ®/ r -7;;r clk6 ,1i .,.,7NG.
/1�'y /.r0 4, ff/` t Pr$ / pa 61)1 0 a 7 4.7 - -a ; filet n /06
Name (Print) Current Mailing Address:
x//11 / n " /3 S 7 5 )
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
c) Construction' from (6)
3. Plumbing erCoe Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �/
6. Total = (1 + 2 + 3 + 4 + 5) 0/l' Check Number/J// }C/ ., / / 62)
This Section For Official Use Only
Bu Perm Number : D ate Issued
I Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2002 -0446
APPLICANT /CONTACT PERSON Valley Home Improvement, Inc
ADDRESS /PHONE P 0 Box 60627 (413) 584 -7522
PROPERTY LOCATION 209 FAIRWAY VILLAGE
MAP 16A PARCEL 020 024 ZONE URA /WSP /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out,_�� keity./.'
Fee Paid �10
Typeof Construction: ADD SHOWER 2ND FLR BATH & ADD BASEMENT LAUNDRY
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 Co sion
Signature of Building 0 cial 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.
209 FAIRWAY VILLAGE ` BP- 2002 -0446
GIS #: COMMONWEALTH OF MASSACHUSETTS
a k :16A 020 CITY OF NORTHAMPTON
Lam.` -ON
Permit: Building
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2002 -0446
Project # JS- 2002 -0677
Est. Cost: $20000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq. ft.): Owner: YANEZ ELVIRA
Zoning: URA /WSP /WP Applicant: Valley Home Improvement, Inc
AT: 209 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:10 /25/01 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD SHOWER 2ND FLR BATH & ADD
BASEMENT LAUNDRY
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/25/01 0:00:00 14111 $100.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo