29-423 (5) � � assRCltttsttle �"�'
DEPARTMENT GB B€1ILDING INSPECTIONS
212 Main Street ' Municipal Building �'� °- A j
Northampton, Mass. 01060 �" } ••
WORKER'S COMTENSATION INSURANCE AFMAVIT
_D1 '� 1aartlxovemerlf , Inc.
with a principal place of busines.-Jresidellce at;
liversrl _ v __ roraplpn,t 01,060 (00110} ( l ) ` 1'
do hereby certify, under the pains and penalties of perjury, thkt:
^5 I am an employer providing the following workes compensation coverage for my
employees working on thi iob
Travelers Insurance Co, ItB888D9983 2/l/01
(insurance Cozy pntzy) (Poticy?umber) (Fxpimt bn Date)
I am a sole proprietor, general contractor or homeowner(circle ode) and have hired
the contractors listed below who Have the following worker's compe ation policies.,
(Name of Contractor) (Insurancc Cornpany/Po cy Ntunbc) ,Expiration.Bate)
(Name of Contractor) (Insura=—ComparyiPolicy Number) (Expiration Date)
t,Name of Coitr ctor) (Insurance Comic atu/PoHcy Nixml�x) (ITExpi tion Date)
(Name of Contractor) jasu once Co atio.�__m
(attach addstiomd shoot Lrneoe ary to� ,oo zupany_Qtr cy Niter) C p ration dale)
to x3l ors)'
} I am a sole proprietor and have no one working for me.
am a home owner;performing all the work myself.
?3C TF—plc:m be as+are that wbile homes w=3 who euVjoy 1aTow to&mxitrr,.uwe cortstrsct on or repair work on a AveJling of
nat uattre than thm un is is which the hauteur resides or an 64 Vvjn43;Vputez Arl tb%dz=-oat gcxm&y cw=kred to be
ezzrrlo xs urdtc tho W*&a elides Act(GLI52 z 1(5))aNUcat m by a ham %.=for a tip or perozit my tvidcnce€ftc
1t9a1 statue of anamployar andcr**WOrkoes cost,
I=dery nd that a copy of thin zftlOmcat away be fos vnuxW to the Duct of hAasftjaj A=&-sve Offiioa of.MIUWW for the
covmgc vaific stioa and drat failure to sectoe o0vaa ge ntada sdctioa 2 5 A of MGL 152 can lean to the i tion of ctscz>ttsat patties
00anains of a fine of up to$1,5109.40 anNor kvriso�of up to ow yrar oral civil penaat es its the form of a SW9 s crone order and a
fim of$194,9()a day_a me
Signed this day of '41000 For depauntaw uaaotly
r ,p Pormit Number
Map# Lot'1
Sim of L' :` "term _
s CTla l$x liiik 1, UCTION SERY.livM . .
:t Ucen$ CflT�tCttiction Sup Cvisor. Not Applicable 0 �
l 060300
c#nsL Haider :_Nelson Sh ff lets
1 Valley Home Improvement~, Inc.
License Number
1
� 320 Riverside Drive 9/02
Address Expiration Date
- Nor t_h�a,-.m_pton, MA.� 0..�1..0_.m6.�_0
5€er at ure ._.
.,._Telephone
1
564-7522
Not Applicable 0 I
Valley Home Improvement, Inc. 105543
Cornpany Name Registration Number
320 Riverside Drive 7/17/02
Address Expiration date
Nort=hapton, MA 01060 _Telephone_- 584-7522
SECftot4 .4-wo,R,KEw, CompENSATIt' N INStlitANIPtE Alr f'IDAVtT(M.G.L.c. 252,§25C(�)) !'
Workers Compensation Insurance affidavit must be completed and submitted with this applications. Failure to provide this of idaJit
will result in the denial of the issuance of the building permit,
Signed Affidavit Attached Yes--, M No...... �
The current exemption for"homeowners"was extended to include Owner-occupied Dwelhn2s of one(l) 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 nets
as su2ervisor.CMR 780 Sixth Edition Section 1.08.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which her'she resides or intends to reside,on which there
is,or is intended to be,a one or two fancily dwelling,attached or detached structures accessory to such use and or faun
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shalt submit to the Building~Official,on a form acceptable to the Building Official,that he/she ;hall be
responsible for all sueh wont performed under the building permit.
As acting Construction Su1„serti isor 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(:
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 Focal Zoning taws and State of Massachusetts General Laws Annotated.
Homeowner Signature --
`c Ct N'5 'DESCRIPTION OF PROPOSED WORK(c eck ail applicable')
i New douse l] Addition 0 Replacement Windows Alteration(s) 0 Roofing Jr
Or Doors El
Accessory Bldg. =l DemolitionO New Signs [ Checks ( Siding E Other F,
Brief Descnpt on of Proposed Work: Q L�4�el /9 4f
{ Alteration of existing bedroom __.Yes 4—T15-
-T1 Adding new bedroom + Yes
Attached Narrative Renovating unfinished basement Yes __._._.._ No
Plans Attached Roll Sheet
a. Use of bu iding : one Family Two Family Other
qb. Nurnber of rooms it each family unit:-, ..... ?umber of Bath rflorr�s _ .-.-
1
.. ? 1
, i:�there a garage attached? .--
d. Proposed Square footage of new construction _ � Dimensions
i e. NUrnber of stories?
Method of heating?—,,. Fireplaces or Woodstoves _- _ Jurnber of each
g. Energy Conservation Compliance.. _ Mascheck 1nergy Compliance form attached?
- 3
Type of construction
1
is construc ion within 100 ft. of wetlands? No. is construct#on within 1100 yr. floodpiain Yes--_-_- ._"�u j
}. Eaepth of basement or cellar floor below finished grade_ ..-_ ..-._. --------
k, Will building conform to the Building and Zoning regulations? Yes __- No .
j ;. :peptic Tank,_. City Sewer Private well City water Supply
f
SECTION a.-OWWNER AUTHpRIZATt4N-TO BE COMPLETED WHEN
OWNEOS ADEN OR CONTRACTtlR ARF'LIES OR BUII.DING ERMIT
Steer Gov Go Qdwj l __._...__....__. _...__ _ "' ` 1 p y
as Owner of fl,,e subject proper"
hereby authorize Nelson yShif fleet, Valley Home Imprc cement , Inc . to act on
} y behalf, in all matters re ive to work authorized by this building permit application.
Signature of Owner Date —� 10 QU
Nelson Shi flett_ , Valley Home Improvemer�t_, ��s Owner/Authorized �+gcr}
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of ray i
knowledge and belief.
Sagned under tiie pains and penalties of perjury.
Nelson Shifflett
eo
, �gnature of owne ent gate
w
Section 4.
n� ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE Bldv
Square Footage %
Open Space Footage %
�Lot area morus bldg&paved
#of Parking Spaces
TO LACK OF A, Has Special Perrnit/Var|ance/Finding INFORMATION
ever been issued for/on the site?
EXiStiDg Proposed Required by Zo j'
Building Department
Lot Size
Setbacks Front
Rear
��
NO DON'T KNQVV YE3________
IF YES, date issued:_____ -----
_____�___
IF YES: Was the permit recorded at the Registry of Deeds?
NO � ~~~--- D{)N'T KNOW YES
IF YES: enter Book Pa8e and/or Docurnent#
B. Does the site contain a brook, body ofwater 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 Ismued:_______________
C. 0o any signs exist on the property? YES NO
IF YES, describe uize, typo and
D. Are there any proposed changes t0or additions of signs intended for the property ?YES
__.
Nn __-
IF YES, describe size, type and location: oc
City of Northampton
r
OCT 0 2000 Belding Department
RON
212 Main Street ' ,. `
s f Rom
Nortflamiaton, MA 0106 �
" + phone 413--5 587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING [
S CTIOfV 1 -SITE INFORMATION
i l,l Property Address; Fhjs section}to he c _e f-1 b Off ;
47 Golden Drive Map, tot tlrtit�,
C
Florence, MA 01062
Zone
O�rerlay fs#era
04"St.0140"kt
SECTION -PROPERTY OWNERSHIP/AUTHOR4ED AGENT
2. 0wner,t Record:
Steve_& G Goodwin 47 Golden Chive
" dame(Pr€nth Curr nt Mailing Address:
-- F orence, MA 01062
Telephone
l Signature 7 • 584-5844
2�2 Authorize Agent: Nelson Shif flett
Valley Hotn e Improvement, Inc._._._ — F.Q. Box 60627 _F1c _erlce, MA 010,62
Name(Print) Current mailing.Address:
584-7522
t ,Signat.rre Telephone
E TI aE j- ESTIMATED COhISTRUCTION COSTS _
1 IteYn Estimated Cost(Dollars)to be Official Use Cnly
i
completed by erm t applicant
W~ building (a) Building Permit Tee
2. 'Electrical (b)Estimated Total Cost of
Construction from 6'
3. Plumbing Bulldin Permit Fern
t
4- Mechanical (HVAC)
; Fire Protection
.6 Total
+2 + 3 + 4 + 5) �� ) Check 1"jmber
Th'rs Section For Official Use Only
Building Permit Number: Cate Issued:
Signature:
Building Cornrmssionerlinspectur Of 8Wdings [Date J
47 GOLDEN DR BP-2001-0374
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-423 CITY OF NORTHAMPTON
Lot:-001
Permit: Am Building
+r.
Category:roofing BUILDING PERMIT
Permit# BP-2001-0374
Project# JS-2001-0607
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sq.ft.): 14374.80 Owner: GOODWIN STEVEN D&GAY L
Zoning.URA Applicant: Valley Home Improvement, Inc
AT: 47 GOLDEN DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.•10 110 100 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER EXISTING 1 LAYER
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 10/10/00 0:00:00 12624 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo