11A-010 � BP- 2010 -0285
GIs #: COMMONWEALTH OF MASSACHUSETTS
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- 2010 -0285
Proiect # JS- 2010- 000370
Est. Cost: $12500.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 29010.96 Owner: WHITE GREGORY W & PATRICIA J REIDY
zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 38 LEONARD ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON. 911712009 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT CLOSET TO BATHROOM & ADD
CLOSET
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 9/17/2009 0:00:00 $75.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0285
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P O Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 38 LEONARD ST
MAP 1 I PARCEL 010 001 ZONE URA(l00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 00 0a 04 qan=
Fee Paid
Typeof Construction: CONVERT CLOSET TO BATHROOM & ADD CLOSET
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Permit DPW Storm Water Management
Demolitio elay
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.
Department use only i
City of Northampton Status of r ei•mit:
Building Department Curb Cut/Dr'ive Permit
Ug 212 Main Street Sewer /Septic AV'aiIaoi;ity
�a R om 100 �Afafer /4 "r'elE Availability
Nori'ha m�ton, MA 01060 Tvdo Sets of Structural Plans
phone 41'31 40 Fax 413- 587 -1272 Plot /Site daps
Other Specify . .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION ' +
1.1 Property Address This section to be completed by office
���� 3 Map Lot Unit
Zone _ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2 Owner of Record D/v
-Name (P Current M1 ailing Address:
Telephone
Signatur C2
2.2 Authori A e t: Nelson Shfflet:t
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA A1062
Name (Print) Current Mailing Address:
701A&W 584 -7522
Signature Telephone
SE CTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
}. Building $ -� D (a) Building Permit Fee
2. Electrical , S� d (b) Estimated Total Cost of
Construction from 6
3. Plumbing �0 8 Building Permit Fee
4. Mlechanical (HVAC)
5. Fire Protect I
6. Total = (1 +2+3+4+5) S (� G Check Plumber q CP
This Section For Official Use Onl
Building Permit Number: Date
Signature:
Building Commissioner /Inspector of Buildings gate r
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: ( tD G R:
+ I + r
Rear
Building Height
Bldg. Square Footage U %
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 —6Z DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO V 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:
- (;TfC' RK j
4N 5. OF-SCRiPTIOIN OF PROPOSED �ViO Lch
A(lditior, Li Roc; I in i
Nv%v Vic: u!,u
Or Coor'.
,%CCES&Ory Bldg. j Demnalitior Ne v. S igns Decks 1 Sidinc Other
- 6wLel A✓ew
63.11 New house arid or addition to exisfiLig housin complete the following;
'
yl-
Pr
S'CT%'CN 7a • OWNER AU - TO BE COMPLETED VMEN
OW14ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Nelson Shifflett, Valley_ Home .Improyement, Inc. - -A :'tf
Nels Sari_ Sb.if-i let -t,—V-all.ey
Home-Impx.o-v-ement.,-Inc-.--,
lt- 11A
Nelson St: i-Mett . ........ -----------
. .
SECTION 8 - CONSTRUCTION SERVICES
J Licensed Construction Supervisor: Not Applicable 0
Name of Licens - e. Holder :—Nelson— Sh.-J. ftle t t 060300
Valley Home Improvement, Inc. Licensc Number
340 Riverside Dr, tnn, MA -10-6
Address Expiration Date
'
Valley--Home Impro- ement, Inc-..- 105543
1 340 Riverside Drive 7/17/10
Ad I dress 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 providc this affidavit
will result in the denial of the issuance of the building pemt.
11. - Home Owner ExeMIDtion
The current exemption for "homeowners" was extended \o include one (1) or two(2) Gn i|[cs
and mallow such homeowner mcn�x�cxn individual knhirrwho does not pnuwc� u license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of rPerson (s) who ovmu parcel o[ land oo which hc./shc resides ur intends to reside, oil 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. ,
Such "honicowner" shall submit to the BUilding Official, oil a form acceptable to tile BUilding Official that he/she shall be
responsible for all such work performed tinder the biflldin�y permit.
As acting Coast ruction Superviso your presence on the job site will bu required from time tvhmc.duriug and upon
completion of the work for which this permit isissued.
Also bo advised that with reference mChapter }5](Y/orkco'Cvmpuxsotion) and Chapter | (Liability of Employers m
Employees for injuries not resulting in Deat of tile Massachusetts General Laws AnommcJ. you may he liable |'(-)r person(s)
you hire (o perform work for you tinder this permit.
The undersi--ried "homeowner" certifies and assurnes responsibility foi compliance with tile State Building Code, C'" of
Northampton Ordinances, State and Local Zonimy Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
♦� a
drIa55RC1J Itfiettlf
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building ' a
Northampton, Mass. 01060
WORKER'S COMPENSATION MURANCE AFFIDAVIT
(Iicenseelpermittee}
with a principal place of business/residence at:
-to 12I dZ16> / .6 2 l� i�`� �/l.��t �'/i%i�U��'1� (phone #) t
(str�Ucity!� tf /� n
do hereby certify, under the pains and penalties of perjury, that:
C4 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
F6 el 5 56 1 — &1 11d
(Insurance Company) (Policy Number) (Expiration Daze)
() I am a sole 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) (Expiration Date)
(attach additional sheet ifnecenary to include information pertaining to all coatracton)
() 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 that whilo homcowuers wtio eraploy persons to do m_ +�+t � mastruetion or repair work on a dwelling of
not more than three units in which the bomeowna• resides or on the grounds appurtenant theesto are not geucslly considered to be
employers under the worker's compensation Act (GL152 fs 1(5)), application by a homeow= for a Uot= or permit may evidende ttx
legal etams of an employer under the Woricae'a Compensation Ace,
I understand that a copy of this may b faiv"u ied to tha Departmoat of Industrial Aecidea& Offioe of lasutitam for the
coverage ve rifie dioa and that failure to sect= coverage under section 23A of MGL 152 can lead to the ikon of criminal penalties
of a fine of up to $1,300.00 stWor fimprisonownt of up to one ytv and civil prnaWts in the form of a, Stop Work order and a
firm of 5100.00 a day against m
Signed this _day of e /5 "(, e , F dgmtnmW use only
Y�6� Mao
Permit Number
Sig= U �tp5 mse vPermittee
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