29-143 CSFA-060300
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PO BOX MW,27
FL()REN('F: NIA 01062
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VALLEY HOlVIE INAPRO:‘,/E\AE..NT
Nelson Shfflet:
P0 Box 6E27
FLOREN;CE MA 010
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VALLEY HOME IMPROVEMENT, INC. JOB ��)�du X63 12j o") /O�
340 Riverside Drive P.O. Box 60627 SHEET NO. � OF
NORTHAMPTON, MASSACHUSETTS 01062 CALCULATED BYL DATE /off • l / -aZ 61 3 -
TEL (413) 584 -7522 FAX (413) 585 -0820
www.valleyhomeimprovement.com CHECKED BY DATE
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m- } -" DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060 �
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, / /ELSO.tf EN iP1- %LL/"% , 1/iAu-Z y f�i-)L -e_ L�'�7 4(/f // 1%, L
(licenseelpermittee)
with a principal place of business/residence at:
3 'f O /e l /Z-4.5 Lb Zie—iii / � /���17 /707,/-, /lilt (phone #) 5 g `q- 7Z2.._.
(str=t/city!stat/zip) 4 / o
do hereby certify, under the pains and penalties of perjury, that:
06 I 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 worker's 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 cootradots)
( ) 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 ague that while homeowners who employ pawns to do m+mr.„rn, our ioa repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not gaserally considered to be
eamloyers under the worker's campmsathon Act (GL152,ss 1(5)), application by a homeowner for a Haase or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Departmart of Industrial AcddeaN Office of Insurance for the
coverage verification and that failure to secure coverage tmdcr section 2SA of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to $1, 500.00 and/or imprisonment of up to o e year and civil penalties in the form of a Stop Work Order and a
fine 0( 3100.00 a day against tae.
Signed this . / $1 day of fi-4 2 For dept use only
/� Permit Number
.!
1 " i.EiAL ` / VSO MapFI Lot
Signature of IS.. ... • ermittee
1 SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shi f f ]e_tt 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA Ai p60 9/22/a.
Address Expiration Date
584 -7522
Signature Telephone
9, Registered Home Improvement Contractor; Not Applicable 0
Valley Home I mprovement , 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 No ❑
1.1.- 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 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 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for persons)
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
'F,,Q S. DESCRIPTION OF PROPOSED WORK (check nfl applicahle)
New House :.11 I Addition Li Replacernent Windows ; Aiteration(s) D Roofing ID
Accessory Bldg. 0 , DemolitionO New Signs : } Decks : ) Siding [ 1 Other '. j
B- lc Dev, on cf. PrCraSee 'I'vO'k Robigi 1 4 ) ,... C ±.8,...1)- . 1
frio
-4 .":0 e„.'0•Is!frip brti:fe:nrn YF,C _ .. , 4 ,...2‘ . AC:1,1p, ri..v.. nkcifoo-r, V..;; .4,,,,
Ate:, Norldtr.t. ke'txr ,ti'i `6,,vntrq
Pb7S k:a: Ror: S
6a. if New house and or addition to existing housing. complete the following:
, use '..)1 DLUICHIE . C., m v T.,63 rant./ _ ()V v „,
1 :
1 : V.; R.:Mt e:'. tr:',7:'''!".F. ri each *ar Ly ir,.t: t
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t. vett- ,D.J. of hcattrig? tpw c ii,,,:i.:,..c.,:e.f.,,,,, 'Ncxxi....tov Nisn'tt...' Uf t.::tch
2
- et :v Ce-servz:Ibi ,•: _ Mescheck Enc•gy C,..; form a*.tacVeci?
Typt.- of cc
.L.;:tici w.tho Ibv,) 1 :.)1m.4.....,s;rics? Yes \Az> is cnstrUCill w VA: !Op yr.
• 71,01 uf nw ..:‘,.! oeltcir l'ic..or cieln. 'ir.r grac;s:
1 1
i k W:1; null:iv cc- fDrm to :he t3wIcirtE: ' nd ?.cnirip, f.;28..datic-!',? Yes
± i. Septic "Tertk _ C 7.y Sew t:....r Pr Va'se we CO,S, vo.atfg Sitn y
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• '
, as 3wner ct tre subject pi ti
I.V 1n7ft Nelson Shif f lett, Valley_ Home.Improyement, , Inc. , ,... .,._,.. ,, , , TO .1i on
rrT.„ L.,... 'I 'nil'. , / ,..'„ , tu , , , ,A)I' , .. c•iutrsc try inif■ L.Ak', ng ;,,, aopiscAlc,
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SIgral°,11` of 04`ler
'...11elson_Shiif1att.___Mialgy Home Imprsntement, Inc. , ;lc : ARK,t
rp dPc'vrc `,;"ir."..1:.• statctncits utto infoir-inuDii (..r1 the (ostr.Roir R aor‘iut:11.101 f#1 k'tft; ottd iscr,-1,1e, to '.11 trez, [) fry
rcwicce„c E. nr..7: bclicf.
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Nelson Shi f f let t— _
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Section 4. �6Y �� GL% Aeoi- SJ eo
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 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:
a
4 ' ' Department use only
r# _... Qty of Northampton S of PIrart
� uilding Department Curb Cut /Dri,, l'mit
212 Main Street
Se / Avaiiabi fy
DEC 2 Q 2012 Room 100 f /Weil A va il abilit y ° ' 4 ' t
NO thampton, MA 01060 T ets of. etUral Plans :
o� r pht 413 87.1240 Fax 413-587-1272 /Sit PI
Othe a
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
0)63 E Di0 Ke Map Lot Unit
A) o Nli p40, . o 6) Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
ODaO/i Car e 1 0)cr-Tc,.-) eJ(il L
Name (Pr Current Ma1� dre
1ve 1 Telephone /
Signatw
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement. Inc. P.O. Box 60627, Florence, MP 01062
Name (Print) Current Mailing Address:
oVI 584 -7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) #o be Official Use Only
completed by permit applicant
1. Building (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 /_
6
Ca
. Total = (1 + 2 + 3 + 4 + 5) I,S QQ , Check Number 3 030 L56
This Section For Official Use Only
Building Permit Numb Date Issued: _._
Signature:
Building Commissioner /Inspector of Buildings Date
263 RYAN RD BP-2013-0671
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 143 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 -0671
Project # JS- 2013- 001111
Est. Cost: $500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 12022.56 Owner: ANDERSON DONALD E & CAROL CHAM
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 263 RYAN RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:12/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REBUILD FRONT STEPS & RAILS
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 12/27/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner