38B-124 (4) dY �a C -
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DE°ART?,,1EN7 Or BUT DIE�\i-; INSPECTIONS
212 Main Street ' 'MiLnicipal Builcing j
Northatnpton, Mass. 01060 �y
WORICR'S CON2ENiSATIOI !�STTR-ANCE AFMAVIT
Nelson Shifflett, Valley Home Im-provement, Inc .
�„*h a p pal place of ounness/residence at:
340 Riverside Dr. , Northampton, M—k, 01060 584-7522
do In ereov ce�—L i y, u- er
Y I m as empiove. pro��di:� &e follo'.ly-:nsz •�er�� s ompe^s��oa cov�:��e . . ._,.
tuaclo��ees wor:�ni on tit S CD:
Acadia Insurance Cc . 0109302 - 11 2/1/06
�,i_^S�u;it:w rO n."i.:•.:^V� 1.OL' _-.�e:2r) �C�,.�: .
C, .. — _ .._._
�.e
c o nu,act ors lis`ec seiow woo Dave the folio"ilf vorke-'s co zi Ce c
�r e 6i CO L i�1c�� Oi]k,� .4 IIL• i r �_.
,N, ,amc of COnia(7:00 ��1SL3nCv COrLC� �'lPCLc� t LII�= �:wLwi v L'a )
:bcd T--tO=-c_j:-0 v:crra.'ioa pC-ta.iyrjg
( ) I am a sole proprietor and have no one working for me.
( ) I am a home ow-ner performing all the work mysel*.
N=-:plcse be avnre tt�w�1e hcmea�xca w'�o c loy pc to cio ^^� ccrw G oa c r weric en a c _g of
nt voce than L�Yw units is-Ech the bamoeuver rs_d=or oe Lila grvjs *r r c^.sai tbccsn arc Doe rc I oo r&i —:a he
e=ployes undocr the%vo i 4 o=p=zlion A=(GL152,=1(5)�rpplictien by a he-c=ax far a Uc a=a per.Da=Y a^d�L"c
1cS21 ru u of as cs ployor un'urthe Workoea Coa:p Lion Act
I LzvL=w nd thst a m7Y of thin mI—uro may bo forwaxdod to the D-:jx of IndLS tial Axidcal 0-100 of I=xrwce for t'.n
oovm-a�;c writ canoe and thst U=to scour_cover�uxdcr stc ioa 25 A.cf MGL 152 can Ia?-to tSo ii93sitica of cr..:.iail pr't cs
oac�of a fine of u?to 51,500.00=&or i r c 1 of up to cac yr r aac!eiriJ perahia in t`s fera of a Step Work ore—&:,d a
cC5100.00 a diy tpiasi-
S igned this, day of ? do s For dew:a1 tt,e�
permit Number
M20 I of N _
4
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 V %
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 hermit 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 propobed ChailP�e5 w of auuiuvna vi Sighs iii�ciiucu io, uic prep-, 3p . 'YES_
No
IF YES, describe size, type and location:
SECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable O
NameofUcenseHolder: Nelson Shiff mkt 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton MA n1060 9/22/Q6
Address Expiration Date
584-7522
Signature Telephone
9. i
Registered 1-110AZIMVProvement Contractor: Not Applicable ❑
Valley Home Impro ent I
vem , nc - _ 105543 _
Company Name Registration Number
340 Riverside Drive _ _ 7/17106
Address Expiration Date
Northampton, MA 01060 Telephone 584-7522
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§ 25C(6))
r�
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afficavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X No... .. 0 I
11. - Home Owner Exemption
The current exemption for"homeowmcrs" was extended to include Owner-occupied Dwellini!s of one(1) or two(?) 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 buildin( 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, CitN of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
I
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ t Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ J Other{
Brief Description of Proposed Work: Aa -/14
A!teration of existing bedroom Yes L-PK- Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes __No
Plans Attached Roll Sheet.
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
Is the,e a garage attached?
I �
c. Proposed Square footage of new cor, tr tip. _ Dimensions
/�
e. Number of stories?
f, iVetho�_ of heat ng? Firepiaces or Vvcodstoves Number o' each
I
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?_
hype cf construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 1-00 yr. floodp!ain Yes No
I 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
i OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERiviiT
! /�/ SlI�CrJl1U F/ ✓ / ��-� l/�l'I 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.
Signature of Owner Date
I, Nelson Shifflett, Valley Home Improvement, Inc- as Owner/Authorized Agent
1er!are th?t the statements and information on the foregoing aoo!ication are true and accurate, to the best of my
knowledge and belief.
Nelson Shifflett
Print Name
A
Department use onty
City of Northampton Status of Pe"
'-Building Department Curb Cut/Drlveway Pew it { h
212 Main Street Sewer/Septic-Avai'abl I
Wa er/Well Avallablli
Room 100 �,��.
r" Nortf tmpton, MA 01060 Two Sets of � iral,Pta „ , � a
J
Jt
phone 413-58 1240 Fax 413-587-1272 Plot/Site Pln K x
Other Speci y
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address: �,f --
0 reSZ-Uf11`J�-j j1/ � Map Lot Unit
Zone Overlay District
Elm St. District___ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2_1 Owner of Record: �G� CdGv 'S
Name P t) Current Uailing Address:
1 J
Telephone , 7/ /
Signature J
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc, P.O. Box 60627, Florence, MA 01062
Name Print) Current Mailing Address:
' - --—
584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
F,F;t mated Cos"Dollars) to be Official Use Only
completed Dy permit applican.t
i
1. Puilding �� (a) Building Permit Fee
+r Cpl (b) Estimated Total Cost of
Construction from o
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4-+ 5) ck Number
This Section For Official Use Only
D<ae '�SUed:
Signature: - ---
Bui!dinp Ccmmissioner/Inspector of Buildings Date --;
File#BP-2005-0871
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 20 COLUMBUS AVE
MAP 38B PARCEL 124 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REPLACE TtJB&TILES IN 2 BATHS
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 LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 on
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.
20 COLUMBUS AVE BP-2005-0871
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 124 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2005-0871
Project# ]S-2005-1206
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq.ft.): 9626.76 Owner: FELDMAN JOEL&PAMELA SCHWARTZ
Zoning: URB Applicant: Valley Home Improvement, Inc
AT. 20 COLUMBUS AVE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.3123105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE TUB &TILES IN 2 BATHS
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 3/23/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo