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c: ;cc> — DEPARTMENT OP •,%s• s: I ;
.m BUILDING INSPECTIONS �,, ;` ;� `_
sa 5 ores•
212 Main Street • Municipal Building -�
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L ._ Nei son._ 1. Shiff let t / Valley Home Tmprovement ,_ Inc .
(Iicenseeipermittee)
with a principal place of business/residence at:
piveratde Drive, Northampton, MA 01060 (phone#) (413) 584-7522
(stn p)
ti
do hereby certify, under the pains and penalties of penury, that:
Q I am an employer providing the following worker's compensation coverage for my
employees working on this mob:
American Int'1 Companies WC00260737000 2/1/04
(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 shod if necary to include information peYtaithng to all contractors)
( ) 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 while hoe owners who employ pazaat to do maintenance, construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grouters appurtenant thereto are not generally considered to be
employer, under the wolcees compensation Act (GL152,ss 1(5)), application by a homeowner for a licrase or permit may evidence the
legal statue of an employer under the Worlcees Compensation Ad.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' Offioe of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MG, 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S 1, 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against me.
Signed this 31 day of c __... -_ _
For d ep,a h na2al use only
I SECTION 8 - CONSTRUCTION SERVICES
a Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shif f let.t 060300
Valley Home Improvement, Inc. License Number
340 Rive _•._ . _ k41, *Lite U= 0 060 9/2204
Address Expiration Date
584 - 7522
Signature Telephone
/ fl /3 »€
te^ /
I - • -ru - u . u - i , t t n , • Not Applicable ❑
Valley Home Improvement, Inc_ 105543
Company Name Registration Number
340 Riverside Drive _ 7/17/04
Address 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 provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes !!D No ❑
11. 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 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 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 who constructs more than one home in a two -year 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 performed 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 persons)
you hire to perform work 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 General Laws Annotated.
Homeowner Signature
'ECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other
Brief Description of Proposed Work: �, j • '!C't, ! V4 /°l J 4 i }e. 7
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Ej Renovating unfinished basement Yes 1/ No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing'housing, complete the following:
a. Use of building : One Family ��� Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? , or Woodstoves _Number of each
g. Energy Conservation Compliance. ., Mascheck Energy Compliance form attached? _
Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ina Luadtke & Genevieve Clarke as Owner of the subject property
hereby authorize Nelson Shif f lett, Valley Home Improvement, Inc . to act on
my beha .II matters re .'ve to wor a t rized by this building permit applicat on.
Signature of Owner Date
I, Nelson Shifflett, Valley Home Improvement, Inc. , as Owner /Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
"Phis column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: I.: R:
It
Rear ' (19'°�"'�
Building Height
Bldg. Square Footage
Open Space Footage
(i.ot 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 V 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:__
Department use only
City of Northampton Status of Prrit; �.
7 B r► Department Curb Cutibil wa P wit
• 21;Z Main Street Sewer /Septic Avarla ity
i }oom 100 W /Well Avallabiht r
Ci; i 3 j . _ ;nNor`th MA 01060 T`QSets of ` �� rat Plan - .
phone 413 - 587.1240 Fax 413- 587 -1272 Plot /SIte P
• Other Speoi
APPLICATION TO 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
301 Fairway Village
Map /6 9- Lot s°1 D Unit v \.
Leeds, MA 01053 ZoncA.P0Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1.Owner of Record: 301 Fairway Village
Ina Luadtke & Genevieve Clarke Leeds, MA 01053
Name (Print) 5 51 Address:
Telephone
Signature
2.2 Authorized Agent: Nelson Shi f f lett
Valley Home Improvement, I P.O. Box 60 Florence,_,_MA 01062
Name (Pri Current Mailing Address:
584 -7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 500 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
._ Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /e Od Check Number 19,8
This Section For Official Use Only
Building Permit Number: (fit'' 533 Date Issued:
Signature: —. __
Building Commissioner /Inspector of Buildings Date
File # BP- 2004 -0533
APPLICANT /CONTACT PERSON Valley Home Improvement, Inc
ADDRESS/PHONE P 0 Box 60627 (413) 584 -7522
PROPERTY LOCATION 301 FAIRWAY VILLAGE
MAP 16A PARCEL 020 031 ZONE URA/WSP/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 7; b 650
T Construction: REMODEL BATHROOM
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 FO 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 Co sion
2 -
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.
301 FAIRWAY VILLAGE BP- 2004 -0533
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A - 020 CITY OF NORTHAMPTON
Lot: -031
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2004 -0533
Project # 3S- 2004 -0753
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq. ft.): Owner: CLARKE GENEVIEVE L &
Zoning: URA /WSP /WP Applicant: Valley Home Improvement, Inc
AT: 301 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11 /10/03 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM
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: Receipt No: Date Paid: Check No: Amount:
Building 11/10/03 0:00:00 17263 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo