23A-014 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
pa '-n
,: Office of Investigations
—`= 600 Washington Street
'sr Boston, MA 02111
. www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Valley Home Improvement, Inc.
Address: , 340 RiversideDlive__ _.
City /State/ :?i D: t
Northampon PROW:' #: _ 413 -584 -7522
- ,--- , _AA�Od 06-
Ar^ you an etnployer? Check the appro;? :late box: Type of project (required):
1. [ X] I am a etnployer with 1• ❑ I am a general contrjctor and 1
12 — 6. ❑ New construction
Irn�r -c (6,11 and /nr part- time)." have Wren the sub- c;antractars
2. [J I am a sr le nt onrietor or partner-
iiszeci on ate aiisLi cd sheet. 7. ❑ Remodeliag
ship ar.d have no enrpltwees These sub contactors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
workirg
g Y . P y cc inswance.t 9. 0 Building t ddition
[No workers' comp. insurance comp.
required.] 5. ❑ We are a corporation and its 10 n Fiertrirai repairs or additions
3.E] I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
['`l
myself, , o workers' comp_ right of exemption per MGL '
Y 12.0 Roof repairs
rPrn,iraA t . c. 152, §I(4), and we have no
employees. [No workers' 13.1X) Other l n5 U l Un
comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inforrrntion.
t Honuvowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 Contractors that check this box must auached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employcts, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Acadia Insurance Company
Policy or Self -ins. Lic. #: WCA5029908 Expiration Date: 2/1/2013
Job Site Address: d q P -^ City /State/Zip: - 1 ienCe , MR 1069d—
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: iv (/ . , t 11 _ Date: t l JaJ-1 I�
1/
Phone 11: 413 -ri • a22.
Official use only. Do not write in this area, to be completed by city or town official f �
City or Town: Permit'I.icense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City,"Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other �t
Contact Person: — _ Phone #: II
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
CS F0
Name of License Holder : Nelson Shif flett _ 060300
Valley Home Improvement, Inc. License Number
PI
340 Riverside Drive, Northampton, MA 01060 9/22/,
Address Expiration Date
G /(ff 584 - 7522
Signat Telephone
9. Registered Home Improvement Contractor; Not Applicable ❑
Valley Hone Improvement, Inc_ 105543
Company Name Registration Number
340 Riverside Drive 7/17/
Address Expiration Date T^
Northampton, MA 01060 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 affidavit
will result in the denial of the issuance of the building permit.
- Signed Affidavit Attached Yes No ❑
11.- Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who 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 and/ or faun
structures. A person who constructs more than one home in a two -vear 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 permit.
As 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 be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _�
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 X 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 X
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 any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
, 1
-1 ,7c TION 5. DESCRIPTION OF PROPOSED WORK (check MI VD1iCable)
1 New House :./ Addition 0 Replacement Windows Atteration(s) 0 Rooting 0
i
Or Doors : I 1
, Accessory Bldg. e3 . 1 D molition0 New Signs : I Decks =', I Siding [ ) Other
I I
9-ic" Dc*.:cm.v, on G Prcpo',..ec. *it-tod‘c Den5e_ pack- oncUr bornpoti Lo(cel1066c La•.(„) • ii- A. Pte_
..... .1 if. ie
pi. pes , Wea...-k-her tz e.,...
,11-,cri. o e;yishnp, her:ra--om Yg-t, ,,c_ \t Ar.:1,118 116:w nfIrtme-' Nei 4 No
:4a.tto Narratr-t Re ,,mfiniblted 1:“.iettiert
Ply ttachc, Por Sne.et
62. If New house and or addition to existing housing. complete the following:
a. .1cf -. ,t :A/dr:111g . C-c. 7 3m iv Tw,r) rarrEly
t
t.: N,Arl'ier o• rm"rs 1 eactl l'arm./ urA: " f.o HF,t1":..cc/nF,
c, lz, t'v n. ga•- alached?
k A r
''' ' . "- ;2;- ” , ' ,IL S ( 0- 441,4 ` IC t?-1 ne°0. ,';.‹.-n-t;or.t : DI-new-K/1
,,..
". 'ic".hoi o' hearne f iwtr; t.:::,es or WoeKit-tov r-L rl coch
cc-serva:icri Oorqp ia Mint:heck Enc Cmphati:e form a:tacheo?
lyr- of co-r-trucben _ __ _....
• -,.cc,.1 wl.hri 1O ft , zrf we ,;.ricIs 'Yes \b. I:, c.:AlstrJcL.7,0 w,:hir 100 yi . 'Ic<Aiplaci Yet, N;)
of ow-ernent c'-! cellar 1 or-r below "Imf.hei grarle
, k W-r 'ou Ith . form to :he Buddinp, -)n,1?_orflnp, r..,;t-,latic"
! L Septic: Erik . C:y Sew-f,-.1 Pr vate. we'-i _ __ city v,,liter sum y
i
"`-------- _,I
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
7c T T eiP re (-LI &GAL._
, as Owner et tre subject voperty.
to Nelson, Shif f let t, Valley Home Improvement, Inc. ..... .. , :0 an rm
MN" bC in d I "liltte.., re ,:tti.'e' 10 v.)ims cnAlie,.iied t'r.. thit, b..1:: tip - it KtplicatnyI
--......;...........—
.iiii■ ______ _ _ __ _______
stkr 2-..0
- Nelson Shifflett— Valley Home Improvement. Inc.. . ;1~, `,.)7:1If-tiAilln0 AE61.t
hub: dec Fle ;ha'. 'Int: ..,tatcrtients :mid wfotrailtroit o- tht,' idoie,',ROirp, Etortid,itiQn 111 t'll drld oecur:ite, to he be el cry
kr cwiecge End bet icl.
th: Dn!"°"..; , ..! ,- 'd r.: LI'
Nelson Shifflet tc.
,_ D;tIe i I 1,911P--
i _ Department use only
City of Northampton Status ofRr
Building Department
Curb Cut /Drdvewaygertat
�' 26 212 Main Street
Sewer /Septic °Avaita fifty
Y
pEPT.OFBUILUiNGINTPEGTIONS Room 100 ' tjf t r /Weil Ave :'' ::1.1";":"'
NORTHAMPTON, MA 01060 rthampton, MA 01060 T'i Setsof r turatPlans` ,
Phone 413 -587 -1240 Fax 413- 587.1272 Plot /Site P}a ; ' ' s ., f ' '
It her Spe i 4 .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I
SECTION 1- SITE INFORMATION
1.1 Property Address: This section to be completed by office '
d q k. 5 , Map _ Lot Unit
` Fi D! Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
J &if S*weJI a PcbrK S , flarenc
Name (Print) Curre t Mailing Addr ss:
i3 ._ 5L _ 63.3 3
, / / ' ; „ / Telephone
Signet e
2.2 Authoriz: • Al - t: Nelson Shi f f lett
Valle Ho.;e Im•rovemen 4 P.O. Box 60627, Florence, MA 01062
erne (Pr' t) Current Mailing Address:
_" 584 - 7522
S' ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1, Building 1 qW 00 (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 t,
6. Total = (1 + 2 + 3 + 4 + 5) 4 c)(?( « OJ Check Number .3ee 7 5 _
This Section For Official Use Only _
Building Permit Number: Date issued:
Signature: ._ — _.
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0590
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 22 PARK ST
MAP 23A PARCEL 014 001 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
76 4tCS-
Typeof Construction: INSULATE UNDER BUMPOUT
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
IN TION 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
7n 1 e1a ,
gnature o ": ui ding 0 icial 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.
22 PARK ST BP- 2013 -0590
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0590
Project # JS- 2013 - 000952
Est. Cost: $900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 17598.24 Owner: STOWELL JETT E & SANDRA D TRUSTEES
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 22 PARK ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 - 7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:11/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE UNDER BUMPOUT
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 11/27/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner