24A-216 $41 t ` (j« } lassrrcltnsrtts __
' '�� }�'= DEPARTMENT OF BUILDING INSPECTIONS , = = _t i _
212 Main Street • Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, L L -50A- E/f / PG.. -L ii 7 v/-/ ;! /fe) 7 P 4'1 -../ /?1/; !fit L
(licensee/permittee)
with a principal place of business/residence at
3 `ie /21 /u?.5 i b 2. i :) Z ,Ae_/ i,i0/t; /V (phone #) `58` 7 ZZ
�st�.
(street /city,..,.:+ :hip) 4 /ao o
do hereby certify, under the pains and penalties of perjury, that:
00 I am an employer providing the following worker's compensation coverage for my
employees working on this job: .
,, Z44e5S L-�'S: :C.) . GA- C 76 O 55 / z////./
(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)
(abaci additional sheet if nec ssary to include information pertaining to all factors)
( ) 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 homcownera who employ pagons to do maintenance, fiction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensatien Act (GL152,ssl (5)), application by a homeowner for a lice= or permit may evident the
legal status of an employer under the Worker's Compensation Act.
I understand that a copy of this sraieavent may be fcawwarded to the Department of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to segue coverage under section 25A of MUL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil pecoitie in the form of a Stop Work Order and a
fine of 3I0O.00 a day against me.
Signed this 3 ' day of 0 G 2'/ 9 For s' use only
Permit Number
Si m of i.�ee'nsee Permittee
•
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I' :` Bitafd 44 Bttittdin” Ret4ti =tti its tattd \I.tttdatrtdN
Construr:lion SL'Per ` ,s—r Lh„e s s �
License; CS 60300
Pe .stricte d to, 1
NELSON A ShhIIFFLETT
340 RIVERSIDE DR PBXSO$27 <*
FLORENCE, MA 01062 t N .
t � � E xpGr atU rn. 9
3435
iiXt. -f 4 i '4 t,7d 3 E. Ft3:l. fsfl 'F >:a 4
Board of Building Fetid iiiitiz>; and Stanttarel
License or registration N. atid for in€ ividul use tSnk
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
Registration: tt}�543
Rc Board or Building Regulations and Standards
r' = One Ashburton Place Tart 11tH
expiration : 7137,2f11€ Tr# 27024
Boston, Ala. 02108
Type: Private Coruorat on
VALLEY HOME IMPROVEMENT `EMENT INIC
Nelson Sh tf,elt ' 2 r
isaei. r, r 'r' f
N anrton, ttra rtn; (j
Not ti ali iitlattttf signature
ztatrt
t[ #r�tirtttitr t4�tt
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shif flett 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA . 011160 9/22/fa
Address Expiration Date
584 -7522
Signature Telephone
/.�
9. Re_ister:Home Improvement Contractor:. Not Appl r able 0
Valley Home Improvement, Inc..._ 105543
Company Name Registration Number
340 Riverside Drive 7117110
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.
rsi Affidavit Attached Yes ;gl No Cl
. -ome Q�rner �t�
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings ()Cone (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 750. 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 1 on co.vv ter.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building OiTicial, 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
'7,CTION 5. DESCRIPTION or PROPOSED vioRK (checj; 0,ppits,-.*Osq
Nem. tic ef.„L. Atdition J Replacement A ter4ticm(!...) Ponfirn
4 0 0i 7 Of Doors,
Accessory Bldg. J Dernolitio- New Signs, 1 Decks Siding Other
Df. t.Ftt r '
712z) /s.4 e frc
t
6.a, If New house and or addition to existing housing. complete the following:
4,71 'g t
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SECTION 7a - OWNER AUTHORIZATION TO DE COMPLETED VittE14
OWNERS AGENT OP CONTRACTOR APPLIES FOP F3UNDING PERMIT
C/t/if,t4i- ZA)14D ,11(--5/1//(/
Nelson Shit flett, Valley Home Improvement, Inc.
• NelSon__Shi filett
A-sty .:IAA.Ac :112 ttent., t ALArAA-AA-A,..A.; it A ink: ,,AtJ
Nelson Shi!flett
)2/17
•
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 4 J —
Side L: R: Itv3 ,j L: R:
Rear
Building Height I ,A) 70i
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 the Registry of Deeds?
NO DON'T KN / 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:
.
.
~
1 Department use only 1
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
- ' - 212 Main Street Sewer/Septic Availability ...........
, Room 100 Water/Well Availability - ,
0,rn 2 - 1146irlhampton, MA 01060 Two Sets of Structural Plans ____ I
phone 413-5874240,, Fax 413-587-1272 Plot/Site Plan,S '
Other Specify '
_
SECTION 1 - SITE INFORMATION
This section to be completed by office
Li Property Address:
7 c� Map_ Lot
| / /1�_ ^m\�- �7,r f���� Zone ________
/
� �«/^r/7r�//��' �� /' �^ ^ `
Elm St. District CB District __ |
SECT 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner nfRecnnd: /�� < .
'j #— /�/� ��� ^ � Z)/�V
| Name ' - ^ - --- ~ -----
0Prin Current wmi|in04du,c�:
=�
~
� 0 i
■ °' �^ Te�pxo
' — ��7 - /�!/ ��'
.ignrtun ~- ~' ~ ~ ~ , ^'
'
2.2 Authorized Agent: Nelson Shifflett
}
Valley Home Improvement, Inc. P.O. Box 60627, Florence,
Name (Print) Current 'MuUinoAd.dmo:
_� 58�-75�2
__ ��x At ^ 1/4111
Signi,tu/e // Te/rpkvne
.
SECTION 3- E5T IVIATE000NGTRWCT|D000STS
!tom | Estimated Cns:.(DoUzu0:o be Ofticia| Use On',
completed bm permit applicant
__
I. Building (a) Building Permit Fee
?/
2. Electrical (b) Estimated Total Cost of
~ IQ Construction from 6)
3. P|umbmg Building Permit Fee
��W�� |
w' |
4. Mechanicu|(HYAC)
5. =ire Protection
| --- - --- �-- �� ��-
6. Total =(l +�+3+4+5) ^]��8pr Check Number �� �� {�
This Section For Q[6cia| Use Only __
Building Permit Nunnber_____ __ ___ Date issued:
___- _-- _ - ' - _ __ _ __ _
Stno uma: _ __ ___ _ _--__-- ------ -- ----
8ui�ingCcmmioionmf|nnpc�or,�Bui|d��s __ Date ___ ___ ____]
���
File # BP- 2010 -0934
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 23 ADARE PL
MAP 24A PARCEL 216 001 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 o26 ?S ' l 4 lD
Fee Paid I
Typeof Construction: MISC INTERIOR REPAIRS, COUNTERTOPS, CABINET DOORS, NEW ROOF
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 FALLOWING 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 Commission - Permit DPW Storm Water Management
Demolition Delay
C q- i 2' I i 0
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.
BP- 2010 -0934
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0934
Project # JS- 2010- 001391
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.): 13285.80 Owner: BERNSTEIN CHARLES J & WENDY F
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 23 ADARE PL
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:4/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:MISC INTERIOR REPAIRS, COUNTERTOPS,
CABINET DOORS, NEW ROOF
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 4/29/2010 0:00:00 $150.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo