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DEPARTMENT OF BUILDING INSPECTIONS �.
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORICER'S COIWENSATION MURANCE AFFIDAVIT
I, Nelson Shifflett, Valley Home Improvement, Inc .
--
with a principal place of business/residence at:
340 Riverside Dr. , Northampton,MA 01060 (phoney#) 584-7522
do hereby certi_ry, under the puns and penalties of per ury, that:
()o I am an employer providing the following worker's compensation coverage for my
employees worlang on this job:
Acadia Insurance Co. 01. 09302-10 2/1/05
(Insurance Company) (Polio Number) (Expiration Daze)
( ) i aul a sole proprietor, general contractor or homeowner (circie one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance CompanyiPolic;Ntunbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dare)
(Name of COP.MC10 ) (Insi ra.nce Company/Policv Numhei) (Expimbon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiothal shoct if accessary to incltsdo information pertaiaing to all oorrtr=t=)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner pelfonning all the work myself.
NOTE:plesac be aware that whilo homeowner:who employ pasons to do mairiiaaaoc,waorvtion or repair work on a dwelling of
not more than throe units is which the homeowner resider or on the get jn&sppurteosut thereto are not generally coandered to be
employem under the worker's ration Act(GL152 is 1(5)�application by a homeowner for a Gerase or permit may evidenoc the
legal&tabu of an employer under the Worlcss's Compamation Ad
I understand that a copy of this uatemmi may be fetwarded to tbo Dopertmcat of Lxkutriel Ana4=&Offioe of 11mase0e for the
coverage venfication and that&dude to segue coverage under section 25A of A OL 132 an read to the imposition of criminal peanitics
ooasLizing of a fine of up to 51,500.00 antler imgriso=crd of and civil penalties in the form of a Stop Work order and a
Seta of S 100.00 a day against ma
Signed this _daLv of G`;� D ��I/ For iep-M."earn only
SECTION 8 - CONSTRUCTION SERVICES
7 1 ironcor4 P:nnctrv1ct1nrl Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shifflet.t 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northam on, MA 01_n6n 9/22/04 _
Address Expiration Date
584-7522
Signature ca—l�
T
9. i-`t r d H,m I ovem n Contractor: Not Applicable ❑
Valley Home Improvement, Inc 105543
Company Name Registration Number
340 Riverside Drive 7/17/06
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....... Z No...... ❑
11. - Home Owner Exemption
The current exemption for"homeow-ners"was extended to include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engaae an individual for hire who does not possess a I icense, 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-vear 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(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,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
w-
r
-ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ 1 Addition ❑ Replacement Windows Alteration(s) ❑ I Roofing
Or Doors ❑
Accessory Bldg. ❑ DemolitionG New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative .- - Renovating unfinished basement Yes ---'No
Plans Attached Roll eet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other --- l
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a d?h
tt
garage attached?
5� �� �"
r�
d. Proposed Square footage of new construction. Dimens;cns I
; I
e. Number of s-ores?
f. Method cr r.e-a'7g? ,.^daces or ` ccdStGves Number of each
g. Energy Conseriat:on Compliance. Mascheck Energy Compliance form attached?
'r
-ype of ccns;ruc:ion
I
1. co r� :' it
is �nst, ct on tin 'CO ft. of wetlands? Yes No. Is construction within 100 vr, flccdciain Yes `�o
I
Depth of basement or cellar floor below finished grade
I
A. Will building conform to the Building and Zoning regulations? Yes No .
i
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
f ✓ �
FGy� /f�jfj?tDUIIC'Z /�tC� o ss� j as Owner of the subject property
hereby authorize Nelson Shifflet V lle Home Im rovement to act on
my half, in all matters relative to work au oriz by this b ilding permit application.
Signature of Owner Date
I, Nelson Shifflett, Valley Home Im;Zrovement 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
Section 4.
ALL LN�'OI AIATION TNPUST BEE COTNrnI,ETED, or PER-MIT 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 J
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:
Department use only
-ai!Nlorthampton Status of It
Building!Department Curb Cut/DitvewaysP
c:„ - „. 12 Main�n Street Sewer/Septic Avaiia 1
Roori 100 W r/Well Avalbi�ity -�
yj
Northafhpto , MA 01060 Two ets off aural Pans � 3
phone`41°3L'587.124� Fax 413.587.1272 Plot/Site P
41-,
Other YSpeci
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 PropertyAddress:
4-?Z / //m /Z10 A'tb Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��uf r� dzde�z rU '%ss� ' �vetic , 1-17* v cob 2 --
' Current Mailing Address:
Telephone
— I
Signature
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
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit a olicant
. 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) R2 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
432 RYAN RD BP-2005-0651
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaR.Block:29- 102 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Bulldinp DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0651
Project# JS-2005-0869
Est.Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Valley Home Improvement, Inc 060300
Lot Size(sg.ft.): 14069.88 Owner: ADAMOWICZ ELINOR T
Zoning_URA Applicant: Valley Home Improvement, Inc
AT. 432 RYAN RD
Applicant Address: Phone: Insurance:
P 0 Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:1218104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE REAR PORCH ROOF HEADER & REROOF
HOUSE
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: Receipt No: Date Paid: Check No: Amount:
Building 12/8/04 0:00:00 18932 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo