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'�: D EPARTMENT OP BUILDING INSPECTIONS „,k = 1
212 Main Street • Municipal Building
1" _ °.
Northampton, Mass. 01060
WORKER'S COMPENSAITON INSURANCE AFFIDAVIT
I, N L.5O 4.i 571 //--9,--,4_677--, v/ L y /10i.x e__ %/ / 4/^> /'Z4i'2i
(Iicenseelpermittee)
with a principal place of business/residence at:
3-to , j/5 / 6 2 J/Z. i /O lf7r97 iDA; g9.1r (phone #) `j 8 `f - 75
(strevt/city!rtn :trip) C/ C
do hereby certify, under the pains and penalties of perjury, that:
(>0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
,(4 55' G/ZS: 6'6 4,0e F6 550 1 2/i1/,�
(Insurance Company) (Policy Number) (Expiration Daze)
( ) 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: plea he aw re that v, c hem re a who employ persons to do maintenance, construction or repair work on a dwelling of
not more than three units in which the homeowner reeicl ea or on the g rounds .y, . -,,_sn a rt °h; elo are not g nll`y coati—l' to b
employers under the worker's enturntration Act (GL152,s 1(5)), application by a homeowner for a licens 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 fwmarded to the Depertn ena of Dial Accident? Office of Insmanoe 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 $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 SI00.00 a day against tne.
Signed this 3'day of /G!7 X2'1'0 For use only
r., /7 Permit Number
e;,, „ a of L rermittee 1
✓922 1.0 a n ✓ i a&taa Office .
fice of Consumer Business ness Regulation e
Regulation License or registration v fo r individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 105543 Type: Office of Consumer Affairs and Business Regulation
-. 7/17/2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT =INC.
Nelson Shifflett
340 RiversideDr.
Northampton, MA 01060 Undersecretary N ?valid without signature
\l:tss:lthusctt; - Dclt t tmcnt of PIN L :t's
Board of Btttl(lin,.; Rt uttl:ttitm, itrul St.tntlytt tis
'`-- Construction Supervisor License
One- and Two- Terily Owelli gs
icense: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062
Expiration: 9/22/2012
( wino is,i:nsiv- ; rr: 2383
1 SECTION 8 - CONSTRUCTION SERVICES
.T Licensed Construction Supervisor: NotA ; ppiicable
Name of License Holder : Nelson Shifflett 060300
Valley Home Improvement, Inc. Lcense Nunmer
1 340 Riverside Drive, Northampton,_A__0106 (1. _ ! 9/22/41___
I Address 1 Expiration Date
584 - 7522
S gi ature Telephone
1 9. Registered Home Improvement Contractor: Not hpplicab'e D
Valley Home Improvement. Inc.,__ 105543
Company, Name Registration Number
340 Riverside Drive _ - 7/
3 Address Expiration Date
I Northampton, MA 01060 Teephone 584 - 7522
1 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
L
Wor'iters Com pensation Insurance affidavit must be completed and Submitted with this application. Failure to provide :Erie affidavit
will result in the denial of the issuance of the building porn
Si fined Affidavit Attached Yes X No 0
I
11. - :Home Owner Exempt
The current exemption for `:homeowners" was extended to include Owner- occupied Dwellings of one ( 1 j or twe(L) families
and to allow such homeowner to cng iue an individual for hire who does not possess a license, rorovided that the owner nets
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 v,°i ie there
is, or is intended to be, a one or two family dwelling. attached or detached structures accessory to such use undi or Minn
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 Builcding Official, that he/she shall be
responsible for all such work performed under the building permit
A. acting con struc`iion t f 3 .
.�r,n i -a�o9 ci.� era. >er�cw a. , dr. :, ;r.f ......:.1. �u ..: , ... ti _,... . � ., � ._
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter i (Liability of Employers t
Employees for injuries not resulting, in Dearth) of the .vlassachusetts General Los Annotated. on may be liable ilor oersotitst
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
iithv i, nton O.dinnaces. State and Local Zoning i. Ewe and date of Massachusetts General I aws Annotated.
,Homeowner Signature
' 7 CTICN 5 WORN l :-...F.T.',,i
Now Fics.g.4.: "...,: Acditien , .J. i Replat.eme Wintlev,5. A turaticm(.) : ' r RocItinr, I
O7 COWS .:
Accessory 6:dg. : Derriclitio : 1 New Signs I Decks Sidirg °tile!
, I
t'' s- tt Ssts : ',"'i s' : st. s s' r ,,s's.: ,o ' -. _.. __ _ f„, , 4,_ _ ___ ilf ( MO I j I 404441 lr
1
6.4. if New loose and or addition to existing housing. cornpietethe_followitm ;
3
e
,..,,:: ...,:.
I ti:, 'I ..%;1", 11 .j P ,. ',--;.-. ,_. ''../ , 4:-. LALML.:.1 , 11 Vw '. i. : Ot ; yi
. ;-. —; ! ' ',...," , :.‘•:,.: ". .... $ -
I: t '.,:. ^.. .-
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. ::k./.:se s ". - :' , 1t , s.; *,t.: Ft.s";•, t 'r :,...".... ,:',.;"," ' :A:v ',!..t.?- ...,"-,,i 21 y
SECTION Ta - OWNER AUTIICRIZAVON ,* TO DE COMPLETED WilEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I
Nelson Shiff ett, Valley Home Improvement, Inc. :, :.t
, 'f', i' . , 0: 4 , ,. " ,-, ',.■;. .t .1 N411 t I , " :'''.;',., ,.. .,, I A 'fr'x i, .: .' ' 4 , : . ' ' ': ;, lr k 1 -
' V
/
.„ .„,,-:,:,.
1 ,
1 .. Nelson_Shi et lett ,__Italley_lione_Impromement ,,_ Inc .
',. I V i' : Ft_ ',* 2.. .' ... l'Isittitss".,.., st SF.' St`f..:1 s - PEG' t''qs,ssi";..St r: t;rs t "., Itis.,:' s;s1 'Istst ,.:"..; tss s , t s!st„ t s s is-. „---, s t t
! i - ..s„, , : scr - cs - rsr, - nrii
Nelson Shifflett
„.:.. ..
, . ..
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: 1) R:
Rear
Building Height g q g . \fi
C
Bldg. Square Footage /o
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 the Registry of Deeds?
NO 1 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:
44 k
w,
' .
. -
__
..^ ,, §` C,.. of Northampton Department use only
Status of Permit:
Curb Cut/Driveway Permit
"' 212 Main Street Sewer/Septic Availaototy
'.4-',... Room 100 watertWe-it Availability
.
'� Northampton, MA 01060 Two Sets of Structural Plans -
,~ ' 'phone 4I3'587'1240 Fax 4I3'5874272
\
_ ' ' -
A REPA�R.RBYOVATEORDEK0OUSHAONE�RTYYOFA�|LY��EQJN
__ DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
-- -- to be completed by office
&� Map ____Lot Unit _
_�
�� � one_ Overlay District _ ___
Elm St. District CB District ________
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:
Cl! .� *�� ��x�w� v
|-- � - - - --- ---
wamr'/ Current — v^w^�
#11.....D �� - -- —'
{ -- ov - / - -- --- �
��'m=
^
2.2 Authorized Age t: Nelson Shifflett
/ .
f
valley Home Inc. P.O. Box 60637, Florence,_
Name(prin0 Current MoU(ngAddnes:
' �/ 58�-75�3
� -�p ^' =� - - -- -- --- --- — --
Signature � T�cnhvne
, _ _
ESTIMATED CONSTRUCTION COSTS
'
Item , Cost (Do||as)to be.. Official Use Dniy
�
completed by permit app|ioan
l Building � (a)Bui|dingPormtFee
) �� �� ' T
7. Electrical (b) Estimated Total Cost of
Construction from (6)
, - 7 , -31 t-r-liDtny I Building Permit Fee
[ _____ __ .:1___________:____L d l i-__
6. :otai = ( + 2 + 3 + ,.4. ± .. , .
I ------- This Section For Official Use Only , _ ...
`, Btailding Permit Number:___ Date Issued: _ _ _
Building Commissioner/Inspector of Building5 Date _
File # BP- 2011 -0781
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 49 BEACON ST
MAP 23A PARCEL 199 001 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 c i •
Fee Paid Uo /r dpoo t,)d r ar,rf rtN�
Tv eof Construction: REPAIR FRONT PORCH FRAMING,DECKING,& RAILS P, I �f l 11 \
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
INFO ATION PRESENTED:
pproved 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
Demolition Delay
/ 5/ - )Il
Signature of Building Official Date I
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.
49 BEACON ST BP- 2011 -0781
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 199 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- 2011 -0781
Project # JS- 2011- 001285
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 64468.80 Owner: GRINNELL WILLIAM D
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 49 BEACON ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01 062 ISSUED ON:3/30/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR FRONT PORCH FRAMING,DECKING,&
RAILS WITHIN EXISTING FOOTPRINT
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 3/30/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner