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`� : f. 5... DEPARTMENT OF BUILDING INSPECTIONS _ 212 Main Street 'Municipal Building 7 , , - - - -=-- - _-_ - "=" - -
Northampton, Mass. 01060 4I am s � :
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, ii/i1-5 0 kr EH / Fp%L& i/ VM - f #0.-it-e_ ,'2 -24 i, c
(licens'eelpermittee)
with a principal place of business/residence at:
3 `f o /11/Z45 l 2 lnJ/ /0. -/lZt %i ; ill, (phone #) 98 q- . zz
(streeticity!satehip) Dto o
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 she if necessary to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one worirkng for me.
( ) I am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do maintenance, construction or repairwork on a dwelling of
not more than three units in whichthe homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the works compensatica Ad (GL152,ss l (5)), application by a homeowner for a lice= cc permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Department of Industrial Amcidm& Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1, 500.00 endlor imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 achy against me. J'�
Signed this . / ! day of / 'G-4 20 /) For dcp rtmatel use mty
Permit Number
el ! ' .,l � LtLW ' A4.41. Map# Lot #
Signature of L1 .. : • ermittee _
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shif fl_ett 060300
Valley Home Improvement, Inc. License Number
340 Rive s 1.0 9/22//2.
Address Expiration Date
584 -7522
Signature Telephone
? ) 1 /
9. Register -d'Home Improvement Contractor: Not Applicable ❑
Valley Home Improvement, Tnc. 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 No 0
ii. - 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 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
r
- i :CTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) i
- -'- •
New House J Addition 0 Replacement Windows ! Alteration() 0 1 Roofing 0
. ,
Or Doors N
i Accessory Bldg. 0 Demolition° New Signs : ) Decks [ ) Siding [ I Other
---- ------------ ...1Z.Z4....1:-Z".,,.:
9 De of Propoied "Aro airSell 1115U tate avcr 3 ,,, , ,,o je G 3Icemose ,, b ,k insu
, 1 - i l
i
41teration o' ovitiner.„ her:tr./m Yr; . /X No, AC:1:np. new flFtntnC/r N ies X No trUt)16trie-4
Attachee Narraitn;I: rierioviAiriii c mfine i llt:i tAsement 'ft t, k N
Plai Attached Roll S-ot ° 40 ru-4, Laic /tic*.
6a. If New house and or addition to existing housing, complete the following;
USE t ouilcing i Crle : Two Family
r) Nomber 17; , h each farnly unit: Numnirr or SEtnfeC,M5 ,
C.. I!; t a i.fr,xage alache0
i
d FR;P:.ntR..; S(;Ltor t; ICOt.'iRe ut new , ;;OnSti i/C( , C)n
ar 1,11.1•Tr-r. or
L 'ilethoi of heating? li"tpriets or Weedstev, Nurnb e of each
e F-erEy Coniservaticn Oorrp ia ti.12scheck Energy Comdlian:e form attactied?
hps of cc^.0ructicn
contr,..:.:ticn w,fht:1 100 , f of w eti , ,;,00s? Yes No, li, constructe witrirr 100 yr. 7 lo<4plain Ytis No
Dcfn of hai,ement or cellar roor nelovii hritshed gr,Ice
k. Wk buildine, CC r form to :he Building werf Zoning rlatic-ir;? _ Ve:",, No
1
t. St-roc lank Cy 5 "a W e t Pr , a.r.ge. %%el City water Supp'y .. i
i .....--
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
" -----
— 7 0 -41 i / S'S 4-4 i i: ,_. ., .... .. _ , as Owner ct tre subject proper ty
heretry . Ne n_ Shit fleth, Valley Home Improvement, Inc. „ _ _ _,,,, „, • _ Ici ant on
rri,,, Liiriiiat!, iv 01 .-16tt Lit to ky, 1 k a [ zed by this 17.-..V:.;'np, oeurit ahpilf,',..iti(,)1
\,, I
,,,., .....
S igna:Jre of pner
...Nalssan shifflett4_Malley HOMO_ Improxement As ,:',....TiftriAlitrayi76:1Agfirit
.
i
hereby declare that the statement's Mid infotriDtton on 1110 fottRoir'Fi atm:lir:Mich Lim !me <Ind aucurate, ti , ,he bet,t, et try
krc....lec pc End bclicf.
S i;Tie :7CC' :t pi is ziir 2:::w`ticri Jr
Nelson Shifflett
PP;r I N;I:r.p1t
SrE:r at iree co ::roii i 7/-
s
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 /Findin 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. Doe t site contain a brook, body of water or wetlands? NO DON'T KNOW ,N
YES /A
4.
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: b ZY1f � S
D. A e t re any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
I S.0 . - -- --" - . i40- r t1l s y :. ✓- Su
' �. - -SQL `y '- . i 2 ' a. , -,:
1 . 1 � 0 \ ` 1, City of Northampton Building Department � � � � ,��� � � a � * ., .�
, p� - _i. a :.
` x as -o_ 1 -- x+a:.,is3�� =xi aMz+ -. w: i
G Q 212 Main Street �. .. t a ik ----,----WIMP t
��N �,r Room 100 Water /We € - P € �
.g � Northampton, MA 01060 a =ar � t A
phone 413- 587 -1240 Fax 413 -587 -1272° r --��
e t ---_.:1,--,' ` '' -z' _.._x .
.,;04 4��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION I
1.1 Property Address:
This section to be completed by office
30a FaI,rtAkUj V 6[ 1 V Map 14 f Lot O1 7 1� Unit ; �
J
Le dS' M4 01°53 zone y ''strict
EimBt•oisltict _ •CB District
SECTION - 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
JO/ , t S 3c �atrt, \! t l l°t62_ _ 1 QS�S, A44-IC
Name Current M aiNn Add
j Ott 3 - 0717
■ ittii =M�.�. — Telephone
'gnature 4--
2.2 Authorized Agent:, JalIlN HOf )C- I !
Nelsen sht- Plea" O box (ooloa�l Ftore nc e � MA- 010(0)._
• Name (Print) Current Mailing Address:
— 4 4 . �{ 13 — 584 — 75c2D—
Signature f Telephone
=SECTION -3 ESTIMATED= CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
300 od _
2. Electrical (b) Estimated Total :Cost ;of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 7 ,2
6. Total = (1 + 2 + 3 + 4 + 5) )O0 , 0e7 C heek Number/ i _
This Section for Official Use Only
Date
BuildingPermit Number i
Signature:
BUirding Commissioner/Inspector of Buildings Date
File # BP- 2012 -0826
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 302 FAIRWAY VILLAGE
MAP 16A PARCEL 020 032 ZONE URA/WP /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out o2 A c
Fee Paid /
Typeof Construction: AIRSEAL,INSULATE OVER GARAGE,VENT BATH FAN,UNSULATE OVERHANG,
ATTTIC
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 l I WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I r ' 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
- moliti on Dela
Ale; `;.1--
' ature of it wilding O facial 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.
302 FAIRWAY VILLAGE BP- 2012 -0826
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A - 020 CITY OF NORTHAMPTON
Lot: -032 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0826
Project # JS- 2012- 001464
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): Owner: LISSAUER JOAN
Zoning: URA /WP /WSP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 302 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:AIRSEAL,INSULATE OVER GARAGE,VENT
BATH FAN,I ISULATE OVERHANG, ATTTIC
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 3/28/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner