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11A-070(1) �a.R��: )4 e lL t�1 of Nazt�antptatt l am__ g .e to 3 4 _s y�l .�.�(!j• Massachusetts s= '_ DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street • Municipal Building �g Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, Nelson A. Shifflett / Valley Home Improvement, Inc. (lrcenseeIpermittee) __... with a principal place of business/residence at: 220 P,ver aisle _Drive, Northampton, MA 01060 (phone#) (413) 584-7522 (strn^..t/cit=/statti-i p) do hereby certify, under the pains and penalties of perjury, that: (X` I am an employer providing the following worker's compensation coverage for my employees working on this lob: American International Companies WC 6554540 00 02/01/2002 (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) (lnsarancc 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 ooreractors) ( ) 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 maimcmac;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 pct(GLI52ss I(5)).application by a homeowner fora license or permit may evidence the legal status of an employer under the Worker's Compematioa Ant I understand that a copy of this statement may be forwarded to the Department of Industrial Aoeideess•Offioo of Imruanoe for the coverage verification and that failure to seine coverage under section 2SA of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to S1,500.00 andlor imprisonment of up to one year and civil penalties in the fora of a Stop Work Order and a fine of SI00.00 a day against me. Signed this 9 day of /J , 2001 For dcparunrilal use only fPermit Number .� _ ✓� 'J�i"'` 11 Map# Lot# Signature of 1,-....0755•ermi r . I•SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Nelson Shifflett 060300 Valley Home Improvement, Inc. License Number 320 Riverside Drive 9/02 Address Expiration Date Northampton, MA 01060 Signature Telephone "tr- 584-7522 II ��1 �e:LE�i°�.r ,t! Not Applicable ❑ Valley Home Improvement, Inc. 105543 Company Name Registration Number 320 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 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 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(sl 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 'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ I Addition ❑ Replacement Windows Alteration(s)% Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ 1 Decks [ ] Siding[ ] Other [ / Brief Description of Proposed Work: bat )41.40 t)'.1`if/c of f a%Gr7v)`/ digh gap 4//411/04/ ,�IJC/13yf Alteration of existing bedroom ____e/Yesi No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _-__L,./No Plans Attached Roll - Sheet i/- 6a. if New house and or addition to existing housing. complete the following: 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? /t/ d. Proposed Square footage of new construction. Dimensions e. Number of stories? Z f. Method of heating? C/7i/ii Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance._ J.//9 Mascheck Energy Compliance form attached? Type of construction f 3 i. Is construction within 100 ft. of wetlands? Yes 1-/-v-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 - 1. Septic Tank City Sewer l/ Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ;. Susan O'Neill , as Owner of the subject property hereby authorize Nelson Shifflett, Valley Home Improvement, Inc. to act on my behalf, in all matters relative to work authorized by this building permit application. Cie Signature of Owner Dat 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 4)i Signature of 0 /7/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 he filled in by Building Department Lot Size �I: Frontage 6Z) Setbacks Front c�, Side L: L:r R: Rear SV Building Height fv ( 1 Bldg.Square Footage `6 % Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) _ A. Has a Spefial 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 D J9OW 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� City of Northampton - ilding Department Cul `� �a 1i2 Main Street power, lyettrot- 1 7 om 100 k is SEP 2 n 2[3rth 4 n, MA 01060 phone 413.5 - 2,0 Fax 413-587-1272 #'4t0` / _ ` ^rar OF BUILDING INSPFC:rinNS APPLICAT4 MPTI4` " .14: • TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1j.1P Address: This section to be completed by office S'3"�roperty E. Center Street Map fi Lot 70 Unit_ Leeds, MA 01053 Zoner,,adi L Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 15 E. Center Street Leeds, MA 01053 Susan O'Neill Name(Print) Current Mailing Address: C� 586-4285 Telephone Signature 2.2 Authorized Agent: Nelson Shi f f l et t Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01.062 Name(Print) Current Mailing Address: 584-7522 Signa ure 11' 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 6;001 Construction from(6) 3. Plumbing /t 9 Ca Building Permit Fee 4. Mechanical (HVAC) ' 5. Fire Protection i 6. Total = (1 + 2 + 3 + 4 + 5) %C 7Q Check Number / 1103/ This Section For Official Use Only Building Permit Number: 11' �� Date Issued:_____ Signature: ___ Building Commissioner/Inspector of Buildings Date File#BP-2002-0350 APPLICANT/CONTACT PERSON Valley Home Improvement,Inc ADDRESS/PHONE P 0 Box 60627 (413)584-7522 PROPERTY LOCATION 53 EAST CENTER ST MAP 11A PARCEL 070 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid /54)(3 Typeof Construction: COMBINE TWO 2ND FLR BEDROOMS&ADD BATH&REMODEL KITCHEN 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 INFO ATION 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 Commission ' O ./ z Ly Signature of Building Officia 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. RA$T,CBNTER$T: BP-2002-0350 GIS#: COMMONWEALTH OF MASSACHUSETTS vatginock.11A..O7O CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:renovation BUILDING PERMIT Permit# BP-2002-0350 Project# JS-2002-0529 Est.Cost: $40000.00 Fee: $125.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Valley Home Improvement, Inc 060300 Lot Size(sq.ft.): 31798.80 Owner: O'NEILL SUSAN Zoning:URA Applicant: Valley Home Improvement, Inc AT: 53 EAST CENTER ST Applicant Address: Phone: Insurance: P O Box 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:10/1/01 0:00:00 TO PERFORM THE FOLLOWING WORK:COMBINE TWO 2ND FLR BEDROOMS & ADD BATH & REMODEL KITCHEN 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 Si¢nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/1/01 0:00:00 14031 $125.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo