18D-038 Property Address: / CA, i i / 3h /i ce
Contractor / Name: / � rr,,-- /�/� ,/ _
Name: /(/ai on 4-/ �Y'7 v de �i� --lid �_1�v
Address: 16O 440,e 6 ,) `7 3V0 € /v i oL7' «2
/
City, State: Na A liA j M
Phone: '1l.3" - 1 /**?; )
Property Owner", l n
Name: C / i ■ v ti 4'// IN I /�� / W-le. 411/1�f' . 7
Address: J 7 ' O 1 SOMA --( •
City, State: /Oa Airy )'fir-- in `
I, / - / (contractor) attest and affirm that the building I intend
to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
( 9.tur
Contractor sign .. i / 7A . c)
Date
/ /'.0)' —/ei
•
9 t,li 'tit 0.1 r of NartItmp hn 1 = *
%V '. ssacfiusrtts _ '—
` mow :�'` DEPARTMENT OP BUILDING INSPECTIONS = _
• 212 Main Street �.
M unicipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
� n
I, /�' /.-504. 57/ /f— = 7% lam -.-- v /ie', e_ ..G-,. -/7 sued. 4> - Le4i - �.dt L
(li censecipermi ttee)
with a principal place of business/residence at:
3 `fog i'/1Z:ie.-5 i lo /)/Z-11 ( A if ,7 A (phone #) 458 ¢.- 7z2_.
(st t/cit i 3yath 0
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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 if necessary to include information pertaining to all cottzaciors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: please he aware th..st while home.•wnere who employ persons to do r_ %m construction or repair work on a dwelling of
not more than three units in which the homeowner mid= or on the a h appurtenant thereto' in ere not g a sai'y considered to be
employers under the worker's •aicn Act (OL15? ,41(5)), application by a homeowner for a lion ca permit may evidence the
legal status of an employer under the Worms Co ; • e ii on Act
I understand that a copy of this r ret. -nit may be f.:.warded to tho Dew of Industrial Axidessti Of oe of insvranca for the
coverage verification and that failure to retre coverage under section 25A of M OL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to $1,500.00 and/or imprisons of up to our year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against use.
Signed this . day of / d I ) : r , 2 t r f 9 For de l use only
�� Permit Number
7: 47 kef ! Map# Lot #
S i .,.... t f i .c
�+T��G Vl li� erlllSrtCC
,
/J n .
•
�'' ✓y C n sine Affairs &sa a Business s Regulation registration only
-t HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 105543 Type: e: Office of Consumer Affairs and Business Regulation
,ice=
, Expiration: 7 /17/2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENTINC.
Nelson Shifflett
340 RiversideDr. ge
j �
Northampton, MA 01060 Undersecretary Nyvalid without signature
1]:lssachtisotts - Dep :l :'tn1wit i f u lid L
Boar of Puildin�y Rc g ul ltion and Stand rr
Construction Supervisor License
One- and Two- v Family Dwellings
L icense: CS 60300
NELSON A SHIFFLETT it
340 RIVERSIDE DR PBX60627 �-
FLORENCE, MA 01062
Expiration: 9 /22/2012
( u� ;ii,iissiu ;nv i rte: 2383
•
f I
SECTION 8 - CONSTRUCTION SERVICES ! `
.3 Licensed Construction Supervisor: Not Appicable
Name of License Holder : Nelson Shiff lett___ 060300
Valley Home Improvement, Inc.
License Number
340 Riverside Drive, Northampton, MA 01060 9/22/1
Address Expiration Date
584 - 7522
Signature Telephone
9 Re_istere ome Improvement Contractor: I Not Ap plicahie ❑
Valley_ Home Improvement, Inc._ 105543
Company Name Registration Number
340 Riverside Drive 7/17/12.
Address Expiration Date
Northampton, MA 01060 Tee,phone 584 -7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I
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....... X No 0 •
1. _ 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 a arts
as supervisor. CiN1R 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 erson who constructs more than one home in a two -year neriorl shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that helsne shill be
responsible for all such work performed under the building„ permit.
As iicting Construction Supervisor your pre,7r'nci; on the .lob sr,� ,l.,l it,: te,iiiirtd r `
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) anti Chapter 153 (Liability of Employers to
Employees for injuries not resultinv in Death) of the Massachusetts General Laws Annotated, w_ou may be liable ,r person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the Slate Building Code, Cite of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated
homeowner Signature
CitCP! DESC.PP; I N or PROP0 st_i tiltt:11",f,c ?; e.,hi; ::
,
idtA ftt:P::,r: ... Ac, itic;t .J. Reel, certPer t Voir:J.t-4.1 t? . a:.tPUSei :,,L i RP`t<Ptirr l._
a t.L'E . -.0 xF'+t . iP mzlittic- i i`+1:cv SigrS I I.JEC'r; r ;i:ei ;g = Otte..
; I
B\ to ali 1CS t,3e
l Y t Vr
6.: If New house and or addition to existing lhoutstslg the following.
/11✓j jvlr17
�i✓s „ /i9, f c ea //d6S'A / - 1 7
”
_ ,„. ,,P ..: 9 "P .:„ ",i4 ' ii,.. ' ... ',:. ..t `,w• .., .. _ ._. . ., t ..Th 4. ._., p61 cE . . '...tq 76 .. ,. t.
$ECT3C , OVair. 4UT SCR ' tTiON TO CE coN1pLET-co 4' tt 14 i
ovaiERs ACFNs OP CONTRACTOR FACTOR `tRP!. TS FOP RUU O FiG PF t'! s 1
a .
1 ! .F ... ,- Nelson Shifll.ett, Valley Home Improvement, Inc. i ,., €
i (/. ) 3 -/o
°a t ..7:,,i;-:-.0' u;.:
. Nels lett,_ Val ey_.._Hone. Ir p ovement, Inc; . t 3 ,
1 f r,. tl2 =E k z` V `: 'ti', t, `t, R E
t *"S1"if. t. eti,. ..
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
..S
Frontage _
Setbacks Front /j
V U
Side L: R: L: J l R: �
Rear 1 V
Building Height 1 tt ' ,
1
Bldg. Square Footage J � % f."1
Open Space Footage °
(Lot area minus bldg & paved G rj
parking) 5 ��
# of Parking Spaces
g
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW IV YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW r,/ YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlancJ /ly(� 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:
i a
■
on ly
City
Department use on',/ ---
City of Northampton .
Status of Permit:
.
. , ,,,,g,■, Building Department Curb Cut/Driveway Permit
212 Main Street ,
Sewer/Septic Availabi
.00m 100 .
Water/Welt Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans_
Other Specify ,
- ..
.. _ ......_
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
. t
Map _ , Lot -- Unit • (:sh . • le it. _
1 Zone __Overlay District
1
Or C70(11,t1,0 Mit GIDloO
t Elm St. District_ __ _ _ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Rec d:
........„
()1 \,J.)uk kAcA
Name (Print) CurreAndr.link .. , y.... 7.... v (..16‘ 0
,,,,tiVrAk Te!eph.Dne I A U C'
.
Signature,
2,2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01052
Name (Prirq Current Stalin Ntdress:
, rr 584-7522
Signature -
I
SECTION 3 - ES IMATED CONSTRUCTION COSTS
Item Esto Cost. (Dollars) to be Official j:,,e 0 n Y
corroleteci oy permit apok.a
1. Buiding _ 35i (20 4.2
irity.%., (a) Building Permit Fee
_
_
9. Electrical (5) Estimated Total Cost of
Construction from (6)
---
---,' El J. P u i! d i rig Permit Fee
. IV.echanical (HVAC)
The ProLJotion _
r . .
6. 7otal = (1 +2 — 3 + 4 + 5) 35:.,e2 0 ` ; ' 1c/Number
This Section For Official Use Only
I --- . ...._
Building Permit Number: Date issued: __
, ____. __....„ ......_
Signature: _ ,, ,_ ■
L____ I BniIdirg Commissioner/Inspector of 3 _ . Lildings Date
_. ...._ _..... ,.._.... _ _.
File # BP- 2011 -0488
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 241 JACKSON ST - HAMPSHIRE HEIGHTS
MAP 18D PARCEL 038 001 ZONE HB/URB(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 0 ?
Typeof Construction: INSTALL CELLULOSE IN ATTICS - BLDGS 1 -17
New Construction A _ ' AMY
Non Structural interior renovations l , (L J' • '
Addition to Existing
Accessory Structure < ' � %Vf P Y// /. 1 SYl IO
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
y
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.
•
241 JACKSON ST - HAMPSHIRE HEIGHTS BP- 2011 -0488
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :B c: I8D .038 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- 2011 -0488
Project # JS- 2011- 000796
Est. Cost: $35000.00
Fee: $210.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 438649.20 Owner: NORTHAMPTON CITY OF NORTHAMPTON HOUSING AUTHORITY
HAMPSHIRE HEIGHTS
Zoning: HB/URB(100) //WP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 241 JACKSON ST - HAMPSHIRE HEIGHTS
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL CELLULOSE IN ATTICS - BLDGS 1 -17
- attic ventilation maintained,inspections during installation
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 11/29/2010 0:00:00 $210.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner