38B-171 t r $ Grid of Nankai aptor F — * -u
NIF .400 . 0 l asaacflnsetts = "
W _ D EPARTMENT OF BUILDING INSPECTIONS M -1111-_------=-7
212 Main Street 'Municipal Building
Northampton, Mass. 01060 IMP
WORIKER'S COMPENSATION INSURANCE AFFIDAVIT
I, WS /-504f EH //''/"-- (/./i1L / .1-- 77/za/i'S� -14 r, L
(licenseeipermittee)
with a principal place of business/residence at: .
3 (-to / i / X $ ! .b d s !) ✓`Z ,i4N; h1 (phone #) 5 8 `'- 2 5 ZZ.
(streeUcity!s',.al hip) aa6 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: .
Acadia Insurance Company WCA5029908 2/1/2013"
(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 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 whirs homeowners who employ persons to do maintenance, construction or repair work on a dwelling of
not more than three units is which the homeowner resides or on the grounds appurtenant thereto arc not generally cccsidered to be
employers the worker's oompeaaatica Act (GL152 fs 1(5)), application by a homeowner for a license or permit may evidence the
legal statue of an employer under the Worker's Compensation Act.
I understand that a copy of this statement may be forwarded to the Department of Inetustri al Acddarts' Office of Iasureoce for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1, 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fins of 5100.00 a day against toe.
Signed this - / 5" day of /3:4 20th. For departmental useonly
Permit Number
J ' . ,/.,4t1ri ` A¢,°. M - Lot #
Signature of LN .r .- • ermittee
?7 eanvrn.9.9uuealtz o/.../ileuoadwieek
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:
�� Registration 105543 Type: Office of Consumer Affairs and Business Regulation
..Expiration; 7 /17/2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROUEMEN1 tNC.
Nelson Shifflett / B
340 RiversideDr.
Northampton, MA 01060 , i !' _
Undersecretary N'; alid without signature
r
Nlassachusctt - Department of Public Safet■
1 n n . Board of Building Regulations and Standards
+ - - Construction Supervisor License
One - and Two- Family Dwellings
License: Cs 60300 xotook
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062 = '
-- i
--�— - i —` Expiration: 9/22/2012
t uininissioner Tr#: 2383
I SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shi f f lett 060300
Valley Home Improvement, Inc. License Number
340 Rive ='.- • ' - b, . • 1 1.1 9/22/12.
Address Expiration Date
584 -7522
Signature Telephone
i
9 Re_ ist - r- dH• a lm' rove en .n r. .r• Not Applicable ❑
Valley Home I' provement:, Inc . 105543
Company Name Registration Number
340 Riverside Drive 7/17/12.
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 lal No 0
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 person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assn e s esponsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local i g } and State of Massachusetts General Laws Annotated.
Homeowner Signature /
, 1
. t;CTION 5- DESCRIPTION OF PROPOSED WORK (check all 1
i ■
1 New House ;:i Addition Li Replacement Windows 1 Alteration(s) C Rooting 0
Or Doors cl
, l
f Accessory Bldg. 0 1 Demolition° New Signs " J Decks [ I Siding I ] Other : }
-- ------;------ -- , . , ....._
ancf Dc`X on of PropoSen NO'k 4ada //eh( - e,k b A •/- hi We r ,
.:■1';eritt■Dn 3' tylsbni- nricroorn _ _YF.r.c: ,,.._ No A1',‘Alp, new ne(iffIC'r Yes No
:•:i.tatifou NorratlY:: Flenov,,iting LnthnisheJ bo:.,efintnt
Fbr s 4tto:lled Roll S'Ittl.:t
6a. If New house and or addition to existing housing, complete the followingi
: e Use ar oinking : One 7 am m I-
T
Iv .,,vo F"l
1,7
. ..
I it N;a11 0" rCOTS -1 each Tar unit: Nunilo.i ot Szthrecms
1 o. l t7rbe rf, garage attached?
:..1 Fft,:pbt,to SQuore fccitesEte al new .:".•<, .11;:tf'..)11 , Drnel'6
a: i4t,ii-» 01
t. Ye't0i of hcatine r i'tp nes of . ..Vcc<itoye,r.,, Nurnber V coch
, g F!'erg'y Cc7servatscn Cor-p ia Nt,stscheel‹, Energy Cprndlian:e form a:tact:co?
1 ype of CC„;11uCbC.
• 'I: CO'PAII.A1(.!i Vie tt i ta J0 1 (4 wet 'Yes No. Is construct :,,n w,:hr I()0 yl '1C-'01101,i,11 Ye:, Nb
Depin of ba!,.ernorit cq cellar Loot nelo../ nrufrred VaCe
, k Yv:1 :..1u.ldr.F, confor-rt to :ne 13,b1..onng and ?OnInft rJaile'f Yes No
l. Septic - 4 , , , nk ( Sewer Pr , vate v.e.d City Vi a ter Sup Y _...--....... i
__,J
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
— "
• „ _ , as Owner ct tre subject property
tr(-rot:y ,t.it'nflr176 Nelson Shif flett, Valley. Home _Improvement, Inc. , . , :0 a : on
my bc. in A rstiotterb r1 to Y.'01 Gott wed by Ibis bci.ng oefsra anplication
AA.
.,........._
st,,,..
a,e. , ()wrier ..,,,,“„
,..Neasszn shifflett, Valley_Home_Improyement, Inc. , ..-i• ',)'.40'16f/Atiln0-17KIARE.nt
hereby dect:Jle ;ha: the statemcnts Drld intrAr-Iztion on the fortioivg noritootion ;,. Nit drvj iiecur,ite, f , ,fie t)et, ef n
krewlecge End belief.
Si;rted _:7cor th: pens 'oPti
Nelson Shifflett—
1 I NAlr,:t
,,,.. III - .1
A.., 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: fi/
0
Rear /(
Building Height [ "
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Specia ermit /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 (.7 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:
•
,.,IECEIVF5
.- .. . > Department use only.
MAR " 7 Z��Z City of Northampton Status' of P,itz
Building Department Curb Cut /Driveway b Peiit r
212 Main Street
SewerlSeptic,Avalta l�#y ry; x � ' �;
DEPT. OF BUILDING INSPECTIONS Room 100
W� /Watt gvalabltlty v,
NORTHAMPTON, MA 01060 �
Northampton, MA 01060 Tw�Sets off= r✓t�ural Plans
phone 413 - 587.1240 Fax 413- 587 -1272 Plot /Site P�, a
Other Specr4 1., -�
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
/7 ale - /Y•A /c`i!% Map Lot Unit
yd Ftel/evice, Zone Overlay District
Elm St. District. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
54 41 4 —
- 'Name nnt) Currentaajliag Address:
/ /24/d i de a46# Telephone�brr JJ
Signature
2.2 Authorized Agent: Nelson Shif f Lett
Valley Home Improvement. Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) 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 560 (a) Building Permit Fee
2. Electrical J (b) Estimated Total Cost of
p� Construction from (6)
3. Plumbing 75D a Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) /Save Check Number v` 95 740- b
This Section For Official Use Only
- Building Permit Number: Date issued:
Signature:
1 Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0776
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC `
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 17 MADISON AVE
MAP 38B PARCEL 171 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 6•7,Q6 y4 ,�j
Fee Paid !! ��
Typeof Construction: REMODEL BATH
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
NF 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
•e ••1 ',n - Ye.
d of Buildm• I fficia Date (/ /.2,.
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.
17 MADISON AVE BP- 2012 -0776
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -171 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 -0776
Project # JS- 2012- 001360
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 8232.84 Owner: MAROTTA MICHAEL L & MICHELE A
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 17 MADISON AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/12/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH
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 3/12/2012 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner