24C-083 (9) BP-2006-0458
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0458
Project# JS-2006-0680
Est. Cost: $14000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sq. ft.): 7492.32 Owner: RADKE MARY BETH
Zoning: URB Applicant: Valley Home Improvement, Inc
AT: 15 MASSASOIT ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11/1/2005 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:
FeeType: Date Paid: Amount:
Building 11/1/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
•
Department use only
City of Northampton Status of Permit:
Building Department i t etwglw;
t7lpr
212 Main Street pig rk3p1EtcAwai }
Room 100 �i R meter/Well Availability 1
--
Northampton, MA 01060 1Two f t c Plans •
phone 413-587.1240 Fax 413.587-1272 ' ,J tot/ ite Plans
0 err S eci
flpop', t r., -
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE R DEIVIO� ISH A ONEQR'..11DAPhItY DWELLING
SECTION 1 - SITE INFORMATION /0 )G}rtio(fu / W J<i ct.s
This section to be completed by office
1.1 Property Address:
/5"-- /97n3S-/05SO/ T Map Lot Unit
/v
t/o/e/- 777- 70x 1771" D/Q‘Q Zone Overlay District
Elm St. District_ CB District
•SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
2.1 Owner of Record: 4.5— 7/7r 515 4—`'Se s/
Name(Print) Current Mailing Address:
Tel
Sig 1:r ✓ —y�.�
2. Authorized Agent: Nelson Shifflett
� , alley 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 permit applicant
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) /WC70 Check Number 2.O2.OS
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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 _ J S V �` .�
Setbacks Front v
Side L: R: t1 L: 04/
Rear / I
1'
Building Height i
b/
Bldg. Square Footage ,o
Open Space Footage
(Lot area minus bldg&paved
parkins)
Z
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 w teds? NO DON'T KNOW
YES
IF YES, has a permit been or need to e 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:
-ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement ows Alteration(s) ❑ Roofing _
Or Doors j
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
t '
Brief Description of Proposed Work: ,T,.,4 s A / / /0 (/[s+y', 't--' t' if Jin r 4 .'w.)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative /� Renovating unfinished basement Yes Nc
Plans Attached Roll _ - Sheet a d7C/46e4 1 kt/,: elc_2 ,S n'I/G71" er,24
6a. If New house and or addition to existing housing, complete lete the following
P
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
Number of stories?
f. Method cf heating? Fireplaces or Wcodstcves Number of each
g. Energy Conservation Compliance. 6" Mascheck Energy Compliance form attached?
Type cf construction
. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
Depth of basement or cellar floor below finished grade
• k. Will building conform to the Building and Zoning regulations? Yes No
:. 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
1. , as Cwner of the subect 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.
ti
Signmisio
Date
I. Nelson Shifflett, Valley Home Improvement, 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. 7/
n
Nelson Shifflett
�
Print Name
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shiffle_tt 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive. Northampton, MA nioFn 9/22/06
Address Expiration Date
584-7522
Signature Telephone
9, Registered Home Imp ement Contractor: Not Applicable 0
Valley Home Improvement, Inr 105543
Company Name Registration Number
340 Riverside Drive 7/17/06
Address Expiration Date
Northampton, MA 01060 Teleahone 584-7522
'SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensatic- ;nsurance affidavit must be completed and submitted with this appiica:ien. Failure to provide this affidavit
will result in the denia. of the issuance of the building permit.
Signed Affidavit Attached Yes li9 No 0
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 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
1•
•�,s. lib. of Northampton IT)
s' �,� giasaarllnsrtts // —
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION rssURANCE AF iDAtiTT
I, Nelson Shifflett, Valley Home Improvement, Inc .
(linse^Jpe:mittee)
with a principal place of business/residence at:
340 Riverside Dr. , Northampton, MA, 01060 (phone""=1 584-7522
do hereby certify, under the pains and penalties of perjury, tha_:
(x) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Acadia Insurance Co . 0109302-11 2/1/06
(T_nsuranca Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general co,nn:actor or homeowner (circle one) and have airei
the contractors Listed below who have the following worker's compensation policies:
(Name of Contractor) t2tisurancc Company/Polie;?amber) (E:cpiratca Da:2)
(Name of Contractor) ;insu anr- CompanwPc•iic'Number) CEA-pima Date
(Name of Cont_*av,or) (Insurance Company/Polk:urnie.:) ;Exp rracc Dare)
(Name of Contractor) (insurance Company/Policy Numhcr) (Expiation Date)
(nnart sdd:tiornl thect ilnecesse y to me.'e i-cormanoa pctaiaicg to all o:z)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plrse be aware that while hemeownera who employ pmecaa to do ram one orzcsrrocioa cr repair work on a dwelling of
not moot than three units is which the homeowner reaidet or on the grounds app rtcaat therdo are not gercnlly coceider to be
employ=un,cr the w,vices con emsation AM(GL152,s 1(5)),application by a homeowner for a license a permit may aid-nee the
legal manta of an employer under the Wcvlcda Compemation Act
I t:ndeat.nd theca copy of this cialcmet may be forwarded to the Depertmeat of loch:xrid Arad Oflioe of Inc ueaca for the
covrzge verifiattioo and that failure to secure coverage under section 25A of MOL 152 esn lac'to(Sc imposition of criotical peatlees
i.ng of a fine of up to S1,500.00 and/or immisoumem of up to cnc year rnd civil peaahies in the form of a Stop Wert Ord.=and a
ft=cf 5100.00 a day against arc
Signed this I / tiny of / :4 dtQC7 5 For al tt,e my
Permit Number
Man4 Lot n
/✓ 450 ..5/f/7-- z%