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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION TSISURANCE AFFIDAVIT
I, Nelson Shifflett, Valley Home Improvement, Inc.
(licens,v&pe:mittee)
Zvith a principal place of business/residence at:
340 Riverside Dr. , Northampton,MA 01060 (Thonei,) 584-7522
iSL7Y°t�C71z
do hereby certify, under the pains and penalties of perTury, the t:
(X)
lam an employer providing the following worker's compensation coverage or my
employees worldng on this job:
Acadia Insurance Co. 0109302-10 2/1/05
(I.nsuzancc:Company) (Policy Number) (r,:_xpiratfbn Daze)
( ) 1 am a sole proprietor, general contractor or homeowner (circle one) and have aired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Inizancc Company/Policy Number) (Expiration Date)
(Name of Contmc*mr) (Insurance Company/Policy Number) ( xpimuon Date)
(Name of Contractor) Jnsuranc--Compa;zy/Polio Nnmbel) (Expimaon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach ad&tioml sheet if noamuy to include infocuutioa perori¢ing to all oomractom)
( ) 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 dA whilo homeowners wbo employ persons to do maintenance,wmuvrooa or repair work on a dwelling of
not more than throe units is which the homeowner r esidca or on the Bounds appurtenam they W art oot generally Wandered to be
employers utrder the w d="-,=Wensation Art(GL152,a 1(S)),applinadon by a homeowner for a Grease a pamA.may evidenoc the
legal staba of an employer under the Worker's Compaosatioa Act
I undersaad thrt a copy of this oxteaxat may be forwarded to the Dopwtrnml of Lxh trill A=dcrl&OfEce of Imuraoee for the
coverage vai&catioo and that failure to sewer:coverage under section 25 A of MOL 152 an lead to the imposi6oa of criminal penalties
oousistiag of a fine of Up to$1,500.00 and/or iapraooaxai of Up to one year and civil penzWes is the form of a Stop Wort order and a
firm of S 100.00 a day against me.
Signed this _der Of G % For dpi use only
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson- ShiffJett 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive,_ Northampton, Ma oinfin 9/22/04 _
Address Expiration Date
584-7522
Signature Telephone
9. Ridstered Ho i
proy-ement Contractgn. 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....... 119 No...... ❑ �
11. - Home.Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellint=s of one(1) 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. C.MR 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 andf 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(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
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows I Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks
Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative L_' Renovating unfinished base ent Yes No
Plans Attached Roll Sheet 11 "
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? i
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? A Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodpiain Yes No
I. 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 Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f
as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement Inc to act on
my behalf, in all matters relative to wo�IRuth "zed by thi u ding permit application.
Signature of Owner 4 Date
I, Nelson Shifflett, Valley Home Im1nrnyementF Tne,- 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 penury.
Nelson Shifflett
Print Name
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
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 L,-"' 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:
r
r -:Department use`only=-;
amity of Northampton Status.at r it ,
-d71B"I ing Department Curb'
� '
;212 Main Street
Sewer/Se pt' k a tatxlil
Room 100
No ampton, MA 01060
'pone 413-58y,1240 Fax 413.587-1272 t?IotlSEte �
. -r
Othee
APPLICATION TObONSTR CT, ALTER, REPAIR, RENOVA S FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
This section to be completed by office
00 ecT 4al& Map Lot Unit
61/J& Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C.112,9S 7--- /0<91
JL
Na e t) ° CurrentVailing AC9
Telephone I
2.2 Authorized Agent: Nelson Shif f lett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name(Prin ) Current Mailing Address:
584-7522
Signature Telephone
SECTION 3 :ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 50-V (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 =(2 + 2 + 3 +.4 + 5) Check Number I Ito
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1300 BURTS PIT RD BP-2005-0491
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-201 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0491
Project# IS-2005-0642
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sq. ft.): 46609.20 Owner: MEISSE DONNA&JOE HAMILL
Zoning: SR Applicant: Valley Home Improvement, Inc
AT: 1300 BURTS PIT RD
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:10120104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 10/20/04 0:00:00 18752 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo