05-019 (3) 277 AUDUBON RD BP- 2011 -0679
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 05 - 019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor renovation BUILDING PERMIT
Permit # BP-2011-0679
Project# JS- 2011 - 001110
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 273992.40 Owner: CARNES RICHARD CHARLES & EMMA JANE
Zoning: RR(100) / /WP Applicant: VALLEY HOME IMPROVEMENT INC
AT. 277 AUDUBON RD
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :211612011 0:00:00
TO PERFORM THE FOLLOWING WORK.- REMODEL BATH
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 2/16/20110:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0679
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 277 AUDUBON RD
MAP 05 PARCEL 019 001 ZONE RRO00) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinjz Permit Filled out
Fee Paid
Typeof Construction: REMODEL BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
_IZApproved 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 Permit DPW Storm Water Management
Demolition Delay
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.
J Department use only
CI of Northampton Status of Permit:
j
�v Bull int; Department Curb Cut /Driveway Permit _ I
Main Street Sewer /Septic Availability _
Room 100 W
�`CY �• ater /b "welt Availability
ortham ton, MA 01060 Two Sets of Structural Plans -
� p �
ne 413 - 587.1240 Fax 413 587 - 1272 Plot /Site Plans
Other Spe j
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pte e A ddress : This section to be completed by office
24
Zone Overlay District_.._._-___
Elm St. District _ - -- CB District.__
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O wner of Record j
f
Na ne (Prntl Current 'aiaili r; r ddress:
Te!ephone
�'ignature
i 2.2 Autho Agen Nelson Shifflett
Va1 H ome I gepro veme nt t In c,,. P.O Box 6 Fl _MA.01062
(`.! nc WrIr �.Sfa llng ,'.(Ar-ess:
58 -7522
I ilt ! ure Tc el.hone
SEC 3 . _- ._ESTIMATED C:UNS't'RUCTIClf±l CAST
It r'l Lstima ',eG Ccs: (Dallcf s;. `0 be Ojii.;iai Use 01
compl ,)y pert - applic -
I _.
Bu ding (a) Building Permit "
2. Electrical / J (b} Estimated Total Co
j st of
Corstruction from
a s o uildi P F
i
i
to _ ` l_.1 2 . 3 5; Cheek Nunn be _ r
1
I This Section Fo Official Us Grsfy
a ,. e- issued: — _ - --
C ,�ilCirr; r emit �vurr.bcr:_ - , _.._._ L�wt., n_
Sionatur a: - --
Bu'ldin. Ci 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 A/1 jgz VA
Setbacks Front )0 C,4 I
Side L: R: O R:
Rear 1 '"
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# 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:
_(`T N : E[_S r € iPT10?v Or.._ PP �POSED %`I,O r, ichc -, `.L , `E
E�taaar EEe.e::.t: :,_ � F.c�lafi�ar: .� � �[��:- Id�tlttr:•a1 �' :'i: °€I��•rs. ,�:�::rsfitrr�(t.� . ": Ettic�Sis,t� €�"
1 ccc &sory Esidg. New . r(s Decks S t
tCElt'�'
Y .
t
• I N ow house acid or additiog to existi ho
qsr €fie cPnap I et th e f�ilc�tiwl�ncy: �
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SCOT €CN rte r C1VO4Cf; AUTHCMZAT Wl TO BE COf"4 PETE D VAIE14
t^4' 14ERS A CUVIT OR Gtd PM`CTd; 9 APPUES COED f3U1iL iCtG PrRfk'E'
y7S -
t . Nelsen Shi Valley Home Irrprovernent, Inc:.
i
! Nelson_.- Shifilett, -. - Valley ._Home -- Improvement,—Inc_....-----_-.
E. , 1 _ _ _:cEr It'' `X' ".Ee' S'"1 4 ,.• iEu iCts !�!_'' `f+ f ',� ) �
Nel Shi`i ett
:710
'
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construct Not Applicable 0
11ey Home Improvement,
i 340 Riverside DriV_e_._1L0_r_thaMptQn, MA -1 0.6�a_
S; Telephone
Vall 105543
Comp rQ Rocristration Number
340 Riverside Drive
Northampton, MA 01060 - Jelephone 584-7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
th
`
1 1. - Home Owner Excuiption
Thc current exemption for "homuovnom'' was extended minc!odo (ooc(1} or u,v(2)buiiieo
t a ll o wsuch horneovaier to en-age an individual for hirewho does not possess olicense,
----�� Homeowne Person (s) who own a parcel ofland oil which he.'she resides ar int-unds to rusidt., un v1hich divi
is. or is intended to be, a one oi two farnily dwelling, attached or detached structuresaccessory to such rise and/ or farin
a two inriod shall not be considered a homeowner.
stmCto
Such' s subrniL to t Building Official, on a forin acceptable to the BUildina Official
be
A^ ymx,prrmo:cwu&c�»h»k/*Gt�oqui'�d�u"h"aad^`^do
comI)iaionv[ the work for which this permit bissued.
Also 'he advised that with refere to Chapter 152 (Worker%' Compensation) and Chnptt!- 1 (LiabilitN �Dn to
J1mpl0ycc,kv}rliubonmren|ringioD^aU)nfduMuodChvseos6uoo|LovoAonntated vou may be fiablit fo,pronn(,)
you hire wpc,k`nn work for you under this pum`it.
Thaundcsigmcd"hvmcnwoc/'couific, and assumes responsibility for comPUuooc*bh the Duu Building Cvdr. City nf
�p'hnnp,nnR:li:ooc�;� ��u/rnodLocz|Znnin�Lan�aod Suoo[\{xs�uchnsesGco:m! Lnvs Annotated.
�., ✓9z2 Ur arzrzaruu2czlCi al ✓�lr�dCia2ude�d
- License or registration valid for individul use only
Oflice.of Cousuincr Affairs & Business Regulation e Y -
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Reulation g
Registration:. 105543 Type: b
Expiration-: -; -. 7F17 /2012 Private Corporation
10 Park Plaza - Suite 5170
" Boston, MA 02116
VALLEY HOME IM ROVEMENT?INC.
Nelson Shifflett /
340 RiversideDr
Northampton, MA 01060 Undersecretary Ngivalid without signature
ett:i
' Boar[l of Buildin _ R 1 ni{m�) ,n(l Stnntl.utll '
ens..
One- :and 1'' jc` - 1 ' i-Ilinras
License: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627�
FLORENCE, MA 01062
i , ion: 9 /22/2012
{ urn�ni..i„n a j r=- 2383
O4 (tiAMp� O
s� � `$ Crz� oaf �,xz #l���it�farr z
$ � �assacflnsrtfs
DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building ' o
Northampton, Mass. 01060
WORKER'S COMPENSATION RiSURA.NCE AFFIDAVIT
(licensee/permittee}
with a principal place of business/residence at:
3 -to 10ilZ S i �- ��i✓`� �IO,�,�� f�%ia/�; �%'/� (phone #) �� 4 1-2 z
(streeticity!�,aL/zip) BiO� C%
do hereby certify, under the pains and penalties of perjury, that:
(4 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insuran Company) (Policy Number) (Expiration Daze)
() Y am a sale proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) ( Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(anarl, additional shed ifnecesss:y to inc de information pertaining to au coohasiors)
O I am. a sole proprietor and have no one working for me.
() I am a home owner performing all the work myself.
NOT E: please to aurae that while h0mr0 =es who employ p== to do m
__M __A n construction or repair work on a dwelling of
nzt more tea theca units is whioh tlx lnomwwntr resides or on lino grounds appurtenant thereto are not daily oDasidemd to be
empioyN= uudex" tha wod -curs omVeasstion Act (GLI52_a I (5)}, application by a homeowner fora Ucm= or psmit may eEridcsce the
legal ctatur of an employer under the Worlix 6 Compansaiioa Act
I understand data copy of this clatcasld may be forwarded to the Departs of Industrial Aec ids Office of Insurance for the
coverage venficM00 and that failure to $== coaeragv under section 25 A of MGL 152 can lead to the krposition of criminal penalties
ooasLsting of a fine of up to 51,500.00 an&or ia2priso mgt of up to one year and civil pcinilties in tbc form of a Stop Work order and a
f= o f 5100.00 a day agsiasi m,-.
Signed this >> ____day of c al` For dal use only
Permit Number
Signatime of LVensee/Permmxittee
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