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DEPARTMENT OF BUILDING INSPECTIONS ='_ �=
212 Main Street • Municipal Building
Northampton, Mass. 01060 am s
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 'nelson A. Shif f lett / Valley Home Improvement L Inc.
O icensee/permrtiee)
with a principal place of business/residence at:
320 Riveraidd_Drive, Northampton, MA 01060 (phone;) (413) 584-7522
(street/ri ty/st a feizi p)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following worker's compensation coverage for my
employees working on this iob:
American Int'l Companies IC.006254374 01-- 2/1/0a
(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 short if necessary to include information pertaining to all contractors)
( ) 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 homeowners who employ persons to do maintenance,construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act(GL15243 l(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Woaiceet Compensation Act
I underhand that a copy of this statement may be forwarded to the Department of Industrial Accidents'Moe 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
coosisting of a fine of up to$1,500.00 and/or imp of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against me. �. /
Signed this /1 day of d'06, , 2002 Fordopatmodaluaoonly
. A.,:;1,_ / / �} Permit Number
0"--• Map# Lot#
Signature of Li•«.9 •ermi'
,
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of Licene Holder. Nelson Shi f f l e t t 060300
Valley Home Improvement, Inc . License Number
340 Riverside Drive 9/02
A.ldress Expiration Date
Northampton, MA 01060
Signature Telephone
584-7522
, „Hl = t: , i n,r , „ . . Not Appicable 0
Valley Home Improvement , Inc. 105543
Company Name Registration Number
340 Riverside Drive 7/17/02
Address Expiration Date
Northapton, 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 1 No ❑
11. Home.Owner,Exemption
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(I) 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 he 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,Cite of
Northampton Ordinances. State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
_'ECT]ON 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [
Brief Description of Proposed Work: ....-/ILLS // J/ J/4 c'r-
Alteration of existing bedroom _Yes L. No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll ,; - Sheet
6a. lfyNewl ous ai o : LtiOr t, I`Igr ousii'1g. completethe
a- Use of building : One Family Two Family ` Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? Ai/ j9
f. Method of heating? Fireplaces or Woodstoves Number of each ,
g. Energy Conservation Compliance. 6 Mascheck Energy Compliance form attached?
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
I, William & Ann Boutelle , as Owner of the subject property
hereby authorize Nelson Shifflett all e _ Hnwe Improvement Inc . to act on
my behalf, in all matters relative to work authori j. .y t rg per 't a •ii�,. n.
if v. -7 >_ -
Signature of Owner Date
I, Nelson Shifflett, Valley Home Improvement. Inc . , 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.
Nelson Shifflett
Print Name
Signature of Owner/Ag: " 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
Frontage
— t —
Setbacks Front t
Side L:
•
Rear 011
Building Height f �t
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:
t
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I��a; 2 in Street ,
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North mtn, MA01060 W :.-
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L--C_ ,t , fi a •12 0 Fax 413-587.1272 r z '
LLr j a .0o�_ 0,i t 1_>. y # - .. c4 -f.+ _, ' `"r
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 co/mjplleeted by office
145 South Main Street Map 3j t.ot , ,'."5 Unit
Florence, MA 01062
Zone Overlay District
Elm St District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 145 South Main Street
William & Ann _ = Florence, MA 01062
Na i Print) Current Mailing Address:
/' 586-1494
Ni , Telephone
S':n. ure
2.2 Authorized Agent: Nelson Shif f lett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
al/ir'i 584-7522
Sign.ture // 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
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total =(1 +2 + 3 + 4 + 5) 5—at•" Check Number /fal6 9— 05-C)
This Sec ion For Official Use Only
Building Permit Number: C j Date Issued:
I Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0064
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P 0 Box 60627 (413)584-7522
PROPERTY LOCATION 145 SOUTH MAIN ST
MAP 23A PARCEL 105 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out //
Fee Paid `)o)('7 5v
Typeof Construction: INSTALL BULKHEAD
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Co ion
Lad 2__.--
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.
MADIST ; BP-2003-0064
GIS#: COMMONWEALTH OF MASSACHUSETTS
N .k:23A-10S CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0064
Project# JS-2003-0150
Est. Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq. ft.): 7710.12 Owner: BOUTELLE ANN E
Zoning:URB Applicant: Valley Home Improvement, Inc
AT: 145 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:7/23/02 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL BULKHEAD
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 7/23/02 0:00:00 15267 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo