18D-053 eoorvi za ff irs �� ✓? License or registration valid for individul use.onl
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\ Office. of Consumer Affairs Business Regula registration y
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 105543 Type: Office of Consumer Affairs and Business Regulation
' 7/17/2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT=INC.
Nelson Shifflett 2
340 RiversideDr. ✓��
Northampton, MA 01060 Undersecretary �N v alid without signature e
Massachusetts Oelr trTnaent of Pul)lic safe
Board of Buildin2 Reuni ation's and Standards
; . z r Construction Supervisor License
One- and Two, rnh riy +Jweldngs
License: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062
E;:pr,ition: 9/22/2012
o3nniissioncr Tr- 2383
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DEPARTMENT OB BUILDING INSPECTIONS
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•. 212 Main Stree c Municipal Building
Northampt on, Mass. 01060 or"'
WORKER'S COM2ENSATION MISURANCE , AFFIDAVIT
//(1---J
(licristercermittee)
with a principal place of business/residence
3 tio / ;3_,,y2,' t5 J .6,; , „) , 44 (phoney!) 8-7z2
(slr . 4 0
do hereby certify, under the pains and penalfes of perjury, that:
V) I. am A n employer providing the following worker's cornperisation coverage for my
employees working on this job:
. ,
55 i 2/2/12
(Insurance Comi=y) (Policy Number) •
(Expira 11on Dwe)
( ) 1 am a sole proprietor, general contractcor or hoineow (circle one) and have hired
the contractors listed below who have tht, following worker's compensation policies:
(Name of Contractor) (Jasilnince Corrrpany/Policy Number) (aTiration Date)
(Name of Contractor) (Insuran Coarpany/Policy Number) (Expiration Date)
(Name of Contractor) (Inaran. Ccrorparry/Policy Number) (Expiration Date)
,
( \ilt - ne of C,ottractor) —7 .
(Iilairar.c Coa3p- lay Nuoib.1) (Expr6on a-A)
(ailath.additicrzil st she if la .—.,1.9.1-3/ to include nde on ii-IF,inin g to ail catrza
( ) 1 am a sole proprietor and have no one working for me.
( ) I am a home owner perfornil_1 pii the work_ myself.
NoTE.': plez_se e avea. Trmt Ng h=g..nwzig,rs , - , ± , -_-• :.-o- -/ .g tn -:!--, 2 :.:7,7,. 7 arlai:g
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oovev vxj-filet awl 'ant faalre to swart 03'& 1_1-tykzo ::-..:1::',a '25 A of MGT- 152 C ,2-d LO t flitl"4 of hs.1 pWAii
ce-----Aistin of a a.... of i to 51,500.00 a. kzpris,rizomeat of alip to) 0= 3,T,ii-13_t_....4 civil pides ill the fom of a Stop Wegit Orer alKI
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-.) Permit Nurrictr
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I SECTION 8 - CONSTRUCTION SERVICES j
.1 Licensed Construction Supervisor: Not Applicable ffl
Name of License Holder : Nelson Shifflett_.__._ 060300
Valley Home Improvement, Inc. License Nu;nber
340 Riverside Drive, Northampton, MA _ 010.6.0- 9/22/,2 .
Address Expiration Date
, 4 / 584 -7522
51:gnature Telephone
• 9. Registered, Horne improvement Contractor: f Not Apol1cab1e ❑
Valley Home Improvement„ _Ina. 105543
Company Name Registration Number
_.]
340 Riverside Drive 7/17/1Z
Address Expiration Date
Northampton, MA 01060 Telephone 584 - 7522 d
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
_.m
s Workers Compensation Insurance affdavit must be completed and submitted with this application. Failure to provide id e this affidavit
will result in the denial of the issuance of the building permit.
I, Signed Affidavit Attached Yes N No 0
1.11
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or twe(2) families
and to allow such homeowner to enure 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 hc.lshc 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 tivho constructs more than one home in a two -near 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 perforated 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 Nvork 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 Gencral Laws Annotated.
Homeowner Signature
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trwali lieu) en4nj remove n - CloSC ,cliyAzttl
6 if New,llotfsc_and_or addition. to existing
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SECTION 7 ovaicr, AUTNORiZAToti TO cE coi valct4
OWNERS AGENT OF CONTRACTOR APRIJES FOR BUILDINO PrRMIT
• Dere:K. Lohl-i-rno,n 04:
r' Nelson Shifflett, Valley Hone Improvement, Inc.
- -
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• NelsonShitliett.,_Aulley_Honte_.Irapromentent.t...._Inc
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Nelson Si!flett
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFOPMATION
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 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:
{
Sof,
•
ECEIVED
Department use oriy
WV 1 5 ZOO r ity of Northampton :Status of P errnit:
uilding Department Curb Cut: Driveway Permit -
DEPT OF BUILDING _ _.� 212 Main Street S eer /Sep Ava
NoRrr+ Room 100 Water /Well Availability
Northampton, MA 01060 Two Sets of Structural Plans`
phone 413-587-1240 Fax 413-587-1272 'Pot /Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DVVELLUNG
I
SECTION 1 - SITE INFORMATION
1.1 Property. Address: / This section to be completed by office
So Damon Rd . , Apf . (O i O / ff Map _ 8 Lot 6S !!
lOnicThamrston I MIN o to r Zone ... Ov #erlay District
Elm St. District -__ CB DistricE _� _-__
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- DeX&C. t,O\ IA- Mo-.n MaO e 67163 -
Name (Print) Current Malin; Address:
Telephone
Signature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc.. P.O. Box 60627, Florence,_ MA 01062
Name (Print) Current Evialing Address:
i /, 584 - 7522
Sigretrr - Te! cphone
SECTION 3 ESTIMATED CONSTRUCTION CTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
corn Meted by permit
_. Building
11000 (a) Building Perm :t Fee
2. Eiectriral (b) Estimated Total Cost of
Construction from (6) —
i 3. Pumbing Building Permit Fee
T
r
f Mechanical (HVAC)
5. Fire Protection
6. Tot ( + 2 3 + 4 ± 5) 41 i � --- Checl; Numb r -
This Section For Official Use Only - -_
i Building Permit Nurrbor: _:__ — Date issued:. --
Signature:
Euifdir Commissioner /Inspector of Buildings to
File # BP- 2012 -0486
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 80 DAMON RD #6102
MAP 18D PARCEL 053 137 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 6� J :Ine/
Fee Paid
Tvpeof Construction: INSTALL 2 NEW ENTRY DOORS, REMOVE AC UNIT - CLOSE IN,INSUL/DRYWALL
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
/—/'
of Building Official Date I I
Signature u g
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.
80 DAMON RD #6102 BP- 2012 -0486
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 053 CITY OF NORTHAMPTON
Lot: -137 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0486
Project # JS- 2012- 000817
Est. Cost: $1600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): Owner: WHITMAN DEREK
Zoning: GB Applicant: VALLEY HOME IMPROVEMENT INC
AT: 80 DAMON RD #6102
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:11/28/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 2 NEW ENTRY DOORS, REMOVE AC
UNIT - CLOSE IN,INSUL /DRYWALL
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 11/28/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner