31A-282 ✓22 ZO Lrz /db d ✓ Ca:ixrTru�ae�Za
Office. of Consumer Affairs Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
-1 Registration: Office of Consumer Affairs and Business Regulation
10 5543 Type: 10 Park Plaza - Suite 5170
Expiration 7/17/2012 Private Corporation
Boston, MA 02116
VALLEY HOME IMPROVEMENT-INC.
Nelson Shifflelt yit
340 RiversideDr.
Northampton, MA 01060 a;- g r/1/' � �
Undersecretary 1`dg valid without signature
•
Nlassachusett4 - Dclt tttmen.t of ,PUh'rt SafCt
Board of Buildan2 Rig ulations and Standards
Const.ruct37n Supervisor of License
One- and Iwo - ' arnilyDwellings
License: CS 60300
NELSON A SHIFFLETT
• 340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062
Exoi;ation: 9/22/2012
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.1/W-NIVe DEPARTM Or BUILDING INSPECTIONS
•
•. 212 Main Street Streel Municipal Building
Northampi Mass. 01060
WORKE S COMPENSATION INSURANCE AFFIDAVIT
I,
4 2 /-5 Af // Li/
(licen...fpernaittee)
with a principal place of bu_siness/residenoe
3 o i ej /2:4,5 j 041 (phone!) 75'21?
(s eVO o
do hereby certify, under the pains and penalies of perjury, that:
0<) I am an employer providing the folloy,, worker's compensation coverage for my
employees worl-,:ng on this job:
jeZti_e5s j2Z-.5: ea. 6.0[2.
(Insurance Company) (Policy Nuxuber) (Esq;iratibn Date)
( ) am a sole proprietor, general CO ntraCt*I° or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:.
(Nathe of Contracter) (Lasiiranoo Comparly/Polic Numkr) (Expiration Date)
----- —
(Name of Contractor) (Insurance Cormpany/Policy Number) (Expiration Date)
(Name of Contractor) anstrrat= Comarry/Policy Number) (Expiration Date)
(l'ilrne ofCo (.11 Coil3p N—uathe) (1 Date)
(intath additicaal se if inacsisaly th iude infolinittEon , g to ell oattoadars)
) I am a sole proprietor and have no one working for me.
( ) T. am a home owner performiL,Ig all th wor mvse
NOTE: p E aware at at
at tact c;co.o 6.‘"
o a 1 , 7.= for a•-7-,a- a may Jao
stat_., of =, e.ta- yuth4 l-
'mot a py es =ate =ay b--1,-,tapos ti=1. Drtr o f 7,2il .0"ffir of 1.- fo th4
CX)VeX Fr&f alld hat faiiure tro =mrag..5 '25j &MGT— 157 ca eAd . 007,5 in -11t1 co of crinliy19.1
srl of a of - 1.31) to S1,500.00 m2.4cr ',Y.,411-1==j t. cof Ji o ono v v;1 Falties the form of a Slop Work Ord gild a
fitv of S1 , ay Eains
fhiS
day 01 / (-127 only
Perrtht Nuinb,17
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of isseti- Termit-t-
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SECTION 8 CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shifflett____ 06
Valley Home Improvement, Inc. L,,cnse Number
340 Riverside Drive. Northampton, MA 010.6.0 9/22//'
j Address Fxpira ol Date
584 - 7522
Signature Telephone
_____Vg . AA4/41
9 Register- • ' ome Improvement Contractor: Not .AppL; cab e 0
Valley_ Home Improvem Tnc.._ 105543
Company Name Registration Number
340 Riverside Drive 7 L17 _ L1
F;ddress Expiration Date
Northampton, MA 0106 Telephone 5 84 -7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (N1.G.L. c. 152, § 25C(6))
I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to providP this affidavit
ivil1 result in the denial of the issuance of the bui ding permit.
Signed Affidavit Attached Yes 20 No %f
11. - tome Owner Excmptian
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings or one (1) or two(2) flurilies
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 k hick 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 -vear period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the [3uildinu Official, that he/she shall be
responsible for all such work performed under the buildintt 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. vou may be liable for person(s)
you hire to perform work for you under this permit.
'fhe 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
. °C T: rt N ar scRiP T CON: r F FTE 3 � `s[ 3 t'ri }{' {: Ec 'f ` w = ,�
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A cas.•o"'j b`.E";;,. _€ CsQ;iiciitic•° L diel"; Sigrs UE ri y —_ Stdit-C tJt!tE " _.
I 4 4 _.,. l uy. 4 4�, ) /. id...' ._ 7/0 r N 6
;Nor ,�.� _J NG d �
ii::, if tfe« _house and or addition to existing ilousin,e, cotnple e the following_
f p p ,
.. .. ► ,. .r¢ '1 ". ".S ;S k F, 4r.� ¢5.'e .., ..k t. t t'.. .I. ►3; sr ,¢Et 1 " 4 . �.i�. .f ....., :.3 E'.
-vr
C CN Tai - OVillt7tR AUTE'UOo- IZAT`.ON . O dIE'��CO�y:f1PLLE!T1�C�sD
C
CWWERS AGENT OP CON ► R-f CTCR A Ers FOR fUILOMG i i „dr� ei ►
Aiii/Z
:w € Nelson Shifflett, Valley Hconte Ii:tp*oventent, Inc.
tie son Shit.f,let.t Hone_ Ir1provernent,__Inc_..
l i _ . 2 __-1h:t _'i. a , k9, F "t�{ �`;g e the:, „ {e 'ee` !t,' �Er , 1.;„ , a , t: ¢
_„1_ a _a ,I.. _ ,_ _ . _. • _ "E
Nelson S2•_ifflett_ _ .,__._... _
1 1 "VA /? - 0).4P )1
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: 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 le eg /siOof 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:
.
E :___-_ j ---; City of Northampton .Status of Permit: '
DEC 3 0 2011 1 Building Department Curb Cut, Driveway Permit -
l , 212 Main Street Sewer/Septic Availability _,
, .:. i Room 100 Water/Well Availability
i . OF BUILDING INSPECTION
NORTHAMPTON, MA 0 10S0 8 11\lorthampton, MA 01060 Two Sets of Structural Plans
p lone Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
`
. X/ r ie 1-0i CA/ kin /
SECTION 1' SITE !NFORMAT|ON if Thiosacdontnbecnnp|eted - by office --- -
1.l Property Address: .
Map ______ Lnt ___Unit______
Zone District
�� ...“/ 0.1.... _--_'
Elm S�0mdr�__ ___�80sbicL_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
r - �� --
2J Owner of Record:
_
��
~--'- --- --- -- � Cu�en �oUinVAddrmo:
^�i / ' / .�/�' -~ - - _ `^" ___ ___ Tn�pxonv '
Signature __
___ _
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc.
Name (Print)
____a_
Signature P.O. Box 60627, Florence, MA 01062
Current Mailing Address:
584-7522
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item I, Estn Cost (Dollars) to be Official Use On'o/
completed by permit applicant ,
1. Building (a) Building PerrnA Fee
2. Electrlcal (b) Estimated Total Cost of
______________ Construction from (6) -- d
3. Plumbing Building Permit Fee
4. Mechanical (1
5. Fire Protection �
6. Tota|=(l+2+3+4+5) , 100 � _ Check Number 1 7 | ����,
This Section For Official Use Only __ ___
Building Permit Number: __ _ __ _ Date Issued: _- _ ._ _____
- - _ _ - _ . __ ___ __
Signature: __ _ ___ __ ____
Building Commissioner/Inspector of Buildings _ _
Date _ __ _ _
*
.,
File # BP- 2012 -0607
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 100 WASHINGTON AVE
MAP 31A PARCEL 282 001 ZONE RR(11)/URA(89) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out i/, et--0
Fee Paid 02 '
Typeof Construction: REMODEL KITCHEN
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
INFORMA N PRESENTED:
proved 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
De w
g
•'gnature of Bui ding • ff ial 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.
100 WASHINGTON AVE BP- 2012 -0607
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 282 CITY OF NORTHAMPTON
Lot: -001 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 -0607
Project # JS- 2012- 001056
Est. Cost: $25000.00
Fee: $150.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 29098.08 Owner: KORFF JEFFREY M & STEUER SHELLY
Zoning: RR(11) /URA(89) //WP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 100 WASHINGTON AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON :1/4/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 1/4/2012 0:00:00 $150.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner