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Valle Horne Improvement , Inc. t he GRINNELL RESIDENCE — —
340 Riverside Drive, PO B ox 60621, Northampton, MA 01062 SCALE: DATE: I
Office Phone 413.584.'22 Fax 413.585.0820 DRAWN BY: I.GOMILLION AS NOTED 12.28.12
_ __ Find us on the web at : uuw.ValleyHomelmprovement.com _
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. -..^. =: DEPARTMENT OP BUILDING INSPECTIONS 4 __1 r
212 Main Street • Municipal Building
Northampton, Mass. 01060 tom'
WORKER'S COMPENSATION IISTJRANCE AFFIDAVIT
1, it/E -5 S'H/ it- - - - 4_6.7r - � v -Ly . '7.7 724/ %, -L
(Iipermittee)
with a principal place of business/residence at:
3 ,740 /l /XS f .b 2 ! ✓'/ 4 //D,07i / i7 (phone #) 5 7, ,
(6-ceticity!st2ithip) el/06 o
do hereby certify, under the pins and penalties of perjury, that:
1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
•
Acadia Insurance Company WCA5029908 2/1/2013"
(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 workers compensation policies:
• (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date) -
(Name of Contractor) (Insurance Company/Policy Number) . (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) - (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all ooatractors)
( ) 1 am a sole proprietor and have no one working for inc.
( ) 1 am a home owner performing all the work myself. •
NOTE: please be aware that while homeowners who employ persona to do maintenance, constructionoor repair work on a dwelling of
not more than throe units in which the bomeowner resides or on the grounds appuwteeaatthereto are not generally considered to be
employers under the worker's oompeasation Act (GL152,ss 1(5)), application by a homeowner fora license or permit may evideoce the
legal status of an employer underlie Worker's Compensation Act.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to SI,500.00 and/or imprisons of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against me.
Signed this - / 5 day of 20/4 For departmeattl use ally
Permit Number •
. I 1 - .,/ ,,,A.Ast ' A" MarN Lot
Signature ofL'r4. . =- •ermitfee
•
•
gze 6 vrz ,nwea /tom a /.,1 'u
`` \ r Office .of. & Business Regulation License or registration valid for individul use. only
1 r , _____...r HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 105543 Type: Office of Consumer Affairs and Business Regulation
_7/ Expiration; - _ 7/17/2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENTINC.
Nelson Shifflett
'
340 RiversideDr. , ____ /�
Northampton, M `"P(�
p A 01060. Undersecretary �/ !�
. -- y Ng alid without signature
r • •
� V] assachusctt. - Department of Public Safct�
Board of Building, Regulations and Standards ds
-- Construction Supervisor License
One- and Two- Family Dwellings
License: CS 60300
e f
NELSON A SHIFFLETT ,," ` I
• 340 RIVERSIDE DR PBX60627 r . "
FLORENCE, MA 01062
�"� �--- Expiration: 9/22/2012
( onuuissioner Tr 2383
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shif f iett 060300
Valley Home Improvement, Inc . License Number
340 Riverside Drive, Northamptnn, MA fli ou 9/22/a
Address Expiration Date
584 - 7522
Signature Telephone
9. Reis e e' ;' a lm: ovem nt .ntrac fr Not Applicable 0
Valley Home Improvement Inc 105543
Company Name Registration Number
340 Riverside Drive 7/17/12•
Address Expiration Date
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 Ilfl 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 heishe 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 farm
structures. A person who constructs more than one home in 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 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 1.53 (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
• 1 :CTION 5. DESCRIPTION OF PROPOSED WORK (check 4 1 I applicable)
t ,
New House —7 1 Addition [J Replacement Windows ; Alteration(s)D Roofing I?,
— .
,
Or Doors :,1 t
' .
Accessory Bldg. D DemolitiorQ New Signs : I Decks ;' ) Siding ( ) Other : )
\ ;
3- D r.;‘, PK ro .itio...c
,L1',r,•fif.i.ion fr e r'i sf trip, bt V- (7,1.1 tp, f'iii,' nfIrtn Ye.-3 ?Jr_-
1
Lttl_tle;; Narratr...tt 14enco,,,,iti; ,..nfinislIci rt
Pb 'S AttinhC.::f Rolf S
63.1f New house and or addition to existing housing. complete the following:
; , t . tif,e. :74 DtAcini, . Cre 7 8r1lly TwO 7 amlly 0:
b F1-re r c4 fcc-rS rf e.leri !,s1 unl: 'Nurnt or 1i.,;ill7fcc,
, Is y-f:te :4. pea& a:tacheo?
' d rruPrx,..14:; S(ti.. tf ki( cf 1 Itt!W .1.0 trod XI! le.i1SIG•r,
ff tsfix of
1. t tetl - oJ o ilrig' f Vet; ;;,:::44:., ur "Neceibtov-,4.:, 1 uf toot,
, e F.7 er;ly cfCr Corlp ia _ M2schock EricTy Csnmplcali:e fzor-rt a:tack:0
Tvpt, :1 co
. 't., cc i uo.ttin 101:11 Or Yes 4..-17 li, cdrt.stt uct6 :AI ov.7,11ir 100 vi . '10 rt.:, ff o I
1 , f,f f i of ofif,errifit ,f*i' celliar 1,nor !)etiovi 41b,it:_heci gfac-e I
k WA1 Mrldtr ff0 form to ale 13wIctne, and ?orient: r44 f,?
NO
Sertic 1 Cy SeWei Pi , ya , fe. we City water Su,OPy
,
SECTION 7a . OWNER AUTHORIZATION .. TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Z(2YL ..6)/i/v /( .
, as 3 cl t _ .uLie,t p „Lnti
f'it riTift Nelson Shiffl t , Valley_
my t bi de ,! , I r-lefers Fet.:113.ie fil cvNi u `C•if try roif, b‘,AH, np. „ a);liCafiC,,
1
&ma:r? of Otvrier
1
-NsaisamShittlett„.._Malley Home Imprsmament, Inc. , ,,i Ap,t
hr doc are iterricnts P;rto rforrnitbori (.r tlitt fbfittRiolf R ilurlic.A10:i ; :ft: ti'ffit; ort(1 flui„;,,rte, Ifs ffie, tfti,`„ tf 1 ivy
kr ewlecge rric belief.
ncd .17 tt psi ar*:i v.:71i. tin Li!'
t
Nelson Shifflet
_
i-3 Nair,ff _
f±ti,!i ItJr.ii:it Cio. le" ^:y -
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
- .1/ 7
Side L: R: a R:
Rear
Building Height 4, ' _
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 any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
department use only
City of Northampton Status of P .riii't.
Building Department Curb Cut /DriveWay Permit
212 Main Street Sewer /SepticAiraiia $�
Room 100 0 : / 4 ell Arias ab�1►ty
Northampton, MA 01060 TAiSefs of �ir ral Plans � >
i r k
phone 413 - 587.1240 Fax 413. 587.1272 Plot/Site P 1
Other Spec r ry* X a
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH � 1'i�i : ' �� DWELLING
�
SECTION 1 - SITE INFORMATION
This s ctio a ett;►,Rl by of flc
NORTHAMPTON, ttig
1.1 Property Addr ess: a GM A 01 060 ec:0 NS
9 igceyd S/. Map Lot unit
P /o&nl G L' Ma. (/Q 6? Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
K � t !!/PM c ihZ ) I 5 09 G'
N Ar gss, 5 � r
2.2 Authorized Agent: Nelson Shiff ett
Valley Home Improvement. Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) /(� Current Mailing Address:
271 4/'/(1 584 -7522
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
3
2. Electrical (b) Estimated Total Cost of
S� Construction from (6)
3. Plumbing 7 5 0 J Building Permit Fee
4. Mechanical (HVAC)
50,4 6 -z��, ord
5. Fire Protection 4[
6. Total = (1 + 2 + 3 + 4 4- 5) Y 7 y(20 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: / .
Buildin g Commissioner /Inspector of Buildings ate
49 BEACON ST BP- 2013 -0688
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 199 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0688
Project # JS- 2013- 001137
Est. Cost: $47500.00
Fee: $285.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 64468.80 Owner: GRINNELL WILLIAM D
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 49 BEACON ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:1/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & 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 1/7/2013 0:00:00 $285.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner