16A-020 (22) The Contmonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.90 v1dia
Workers' Compensation Insurance,Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizationdndividual): �QLqfkA JM,( ' fW,,21VWMer_)+
Address: �
City/State/Zip: Q %�A 52Z
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with 1�3 4. n I am a general contractor and 1 6. n New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in,any capacity. employees and have workers' 9.. EJ Building addition
[No workers' comp.insurance comp.insurance.1
required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.r_1 I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.n Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.M Other
employees. [No workers'
comp.insurance required.] I
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �b6Ao, G cbu
Policy#or Self-ins.Lic.#: oo(J,:E)06o-2 Expiration Date: aa.
–L—
Job Site Address:&D 2A:Y �CX,ta City/State/Zip:let-,4s 0 0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage v/erification.
I do hereby ceAthepinns�alldfpenalti perjury that the information provided above is true and correct.
Date: h
Signature: A
Phone#: cor
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: .Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,�L Commonwealth of Massachusetts
! Division of Professional Licensure
UV Board of Building Regulations and Standards
Conpervisor
rf
CS-112166
�-1 Wires: 06/01/2021
� ��
RACHEL K ROBERTS� r
J(��10 CHAPMAN AVE ,
EASTHAMPTON MA 01027 '>
Commissioner
�l�Pi ���'fi�'li�/�iC�����i�r��ci i����1�-Qii��C�C�c:►�(i�
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improve mentiContractor Registration
Type: Corporation
VALLEY HOME IMPROVEMENT INC ;; f<�fi Registration: 105543
P.O.BOX 60627 � � __ Expiration: 07/16/2020
{
FLORENCE,MA 01062 ( T y
Update Address and Return Card.
SCA 1 20M-05//11177
7e c�rm�2cieccea�i�o� aJJ¢c�iJellJ.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE,, orporation before the expiration date. If found return to:
Registration.' Expiration Office of Consumer Affairs and Business Regulation
105543 07/16/2020 One Ashburton Place-Suite 1301
—� Boston,MA 02108
VALLEY HOME;IMP-RQVEMENT=1►VC
STEVEN A.SILVERMAN ;d
340 RIVERSIDEDR��;��
!
A`
NORTHAMPTON,M01062 Undersecretary Not valid without signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 3bD F2Aa w V1 lay 4 3b
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant ala
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suu �e(rvisor: I Q Not Applicable ❑
Name of License Holder: ,1 1� LTJ , 1 a/&&
License Number
ICS eC 6,11 12-62/
Address Hh C107-) Expiration Date
X113- 58LI--I52-2-
Signat Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
allw _T c�r, /j35,5 `13
Comps v Name Registration Number
CX)- Lof7lolee7ein N6 D1 b lot 7 W /ZO26
Address Expiration Date
Telephone
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....... fYinNo...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings 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.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 buildine 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)� Roofing ED
Or Doors ID
Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [Q Siding[0] Other[Q]
Brief Description of Proposed
Work: 91 T CH OJ Ae1 dV4flaN yV/ AA-1-W k FiX IVAeE-- 40 Ji 1&7&-,R11Z 0"Vxws _
Alteration of existing bedroom Yes_XK No Adding new bedroom Yes )16 NoAb C NipNG
Attached Narrative Renovating unfinished basement Yes X7 No � rb
Plans Attached Roll - heet e /G2
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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes 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,
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
I,_&Yr7 evc CLtaYk-c 4--,T476L 1-UqdJ-kx_ as Owner of the subject
property
her authorize J�T
to a t n my behalf,in all m rs ative work authorized by this buildingper 't application.
l
Sign te of Owner lbate
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 u der the pains and penalties of perjury.
�U1i1/ a fa L v
Print Name �i
�'dd
Signature of Owner Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 0 DON'T KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page; and/or Document#?
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I\/ Department use only
V ity o Northampton Status of Permit: :,
IOU g Department Curb Cut%Driveway.Permit
NOV 1 5 2018 212 Main Street Sewer/Septic Availability_
00m 100 Wate r/Vl/ell Availability
ha pton, MA 01060 Two Sets of Structural Plans
DE=NORTHAMPT
BUILD �^p C,��I
ta' �87- 240 Fax 413-587-1272 Plot/Site Plans
OEher Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
i y�00:5
1.1 Property Address:
This section to be completed by office
\� la-,-a)
(�
3W F V ) )l ,U� vn!4- Map U A-- Lot O d O Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
m V t Nj . 1 5 - wo
N (Print) Current Mailing ddr s - -
% Ste- 5i4
Telephone
ign ture
2.2 Authorized Agent:
u
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z -7 Xp" (a)Building Permit Fee
2. Electrical 0,90 (b)Estimated Total Cost of
Construction from 6
3. Plumbing ` '90 .0 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 +2 +3+4+5) q 70 Check Number b
This Section For Official Use Only
Building Permit Number; Date
Issued;
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2019-0603
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 360 FAIRWAY VLG
MAP 16A PARCEL 020 000 ZONE URA(102)/WP(171lWSPt15)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONINGFORMFILLED OUT
Fee Paid
Building Permit Filled out 1A
Fee Paid
Typeof Construction: KITCHEN RENO
New Construction
Non Structural interior renovatigpA-
Addition to Existing
----
Accessory Structure
---
Building Plans Included:
Owner/Statement or License 112166
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
Approved 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 Commission Pen-nit DPW Storm Water Management
—Demolition Delay
it
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.
360 FAIRWAY VLG BP-2019-0603
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 16A-020 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: KITCHEN RENO BUILDING PERMIT
Permit# BP-2019-0603
Proiect# JS-2019-000980
Est.Cost: $34700.00
Fee: $242.9Q PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 112166
Lot Size(sa.ft.): Owner: CLARKE GENEVIEV,E L&
Zoning:URA(102)//WP(17)/WSP(15)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 360 FAIRWAY VLG
Applicant Address: Phone: Insurance:
P O BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:11/28/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN RENO
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 Dena�r Ment 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 §ienature•
FeeType: Date Paid: Amount:
Building 11/28/2018 0:00:00 $242.90
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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340 Riverside Drive, PO Box 60621, Northampton, MA 01062 Leeds,MA01053 ELECTRICAL PLAN DATEA1/12/2018
Office Phone 413.584.7522 Fax 413.585.0820 CLARKE/LUADTKE DRAWN BY:RKR 7
Find us on the web at: uAAAA).Valle Homelm rovement.com
This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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340 Riverside Drive, PO Box 60627, Northampton, MA 01062 Leeds,MA 01053 DATE11/12/2018
Office Phone 413.584.7522 Fax 413.585.0820 CLARKS/LUADTKE C DRAWN BY:RKR 6
Find us on the Lueb at: u�uw.Valle Homelm rovement.com
This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
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340 Riverside Drive, PO Box 60621, Northampton, MA 01062 Leeds,MA 01053 DATE:11/12/2018
Office Phone 413.584.1522 Fax 413.585.0820 CLARKE/LUADTKE B DRAWN BY:RKR
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This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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340 Riverside Drive, PO Box 60621, Northampton, MA 01062 Leeds,MA 01053 DATE11/12/2018
Office Phone 413.584.7522 Fax 413.585.0820 CLARKEILUADTKE A DRAWN BY:RKR 4
Find us on the web at : uAAAv.Va11eL4Homelm provement.corn
This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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340 Riverside Drive, PO Box 60621, Northampton, MA 01062 Leeds,MA 01053 NEW WORK DATE 11/12/2018
Office Phone 413.584.1522 Fax 413.585.0620 CLARKE/LUADTKE DRAWN BY:RKR 3
Find us on the web at: www.Valle HomeIm provement.com
This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any form
for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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340 Riverside Drive, PO Box 6062'1, Northampton, MA 01062
Office Phone 413.584.7522 Fax 413.585.0820 CLARKE/LUADTKE CONDTIONS DRAWN BY:RKR 2
Find us on the web at : uA w.Valle Homelm rovement.com
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PROJECT NOTES:
PROJECT PLAN ML
Na
E E THI5 PLAN SET,COMBINED WITH THE BUILDING CONTRACT,PROVIDES BUILDING DETAILS FOR THE RENOVATION OWNER: GLARKE/LUADTKE E
INDEX OF DRAWINGS W O O
E o PROJECT. THE LEAD CARPENTER SHALL VERIFY THAT SITE CONDITIONS,AND DIMENSIONS ARE CON515TENT WITH TITLE SHEET > z
°o THESE PLANS BEFORE STARTING WORK.WORK NOT SPECIFICALLY DETAILED SHALL BE CONSTRUCTED TO THE SAME PROJECT 360 Fainuay Villaige,#301 PROJECT SUMMARY 1
S
QUALITY A5 51MILAR WORK THAT 15 DETAILED.ALL WORK SHALL BE DONE IN ACCORDANCE WITH INTERNATIONAL EXISTING CONDTION5 2 f—
o NEW WORK 3 L m
3 BUILDING AND LOCAL CODES. ADDRESS: Leeds,MA GABINET ELEVATIONS A 4 Q O �
r
CAB NET ELEVATION5 B 5 `D
CABINET ELEVATIONS G 6
,�" \) `— ` y+"•"` WRITTEN DIMENSIONS AND SPECIFIC NOTES SHALL TAKE PRECEDENCE OVER SCALED DIMENSIONS AND GENERAL BLDG PERMIT: ELECTRICAL PLAN -1 ry
NOTES.THE SALE PER5ON/DE5IGNER SHALL BE CONSULTED FOR CLARIFICATION IF 517E CONDITIONS ARE �
,y'n ENCOUNTERED THAT ARE DIFFERENT THAN SHOWN,IF DISCREPANCIES ARE FOUND IN THE PLANS OR NOTES,OR IFA DESIGNER: RKR
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10 1 ♦ ♦ QUESTION ARISES OVER THE INTENT OF THE PLANS OR NOTES.CARPENTER OR 5UB-GONTRAGTOR SHALL VERIFY AND
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