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d yd PROSPECT STREET
NOTE:
THE PURPOSE IS PLAN IS INE PHYSICAL
ENCUMBRANCES ON E PR FOR USE BY
• I LENDING NSTITUMCN GAGE AND TITLE INSURANCE
_ ■■■•• 0°1e,, A a •s—i—bihrs A 444'1 P I% Int lin A A le neN.
•
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9 ;.`� >� Crxt itf N.:z#llamp-fon *_�
4 1! Aassaclinsetts _ =
DEPARTMENT OF BUILDING INSPECTIONS 4 _ ? ?_I f
212 Main Street °Municipal Building = 5
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE FIDAVIT
yy 1
�l —5(5k �
.!-, /V' J S% � f %= f`'�-- �- - /� dJ . / <y1--�-; . 5) //°t .i � � /!", > !l'C.
(licenseeJpermittee)
with a principal place of business/residence at:
3 `icy T I /L � i � /IL/1Z ,7 4/7 /i t (phone #) f5 % Z2_.
do hereby certify, under the pains and penalties of perjury, that:
(A I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(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 Numb: r) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration} Date)
(Nance of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atacia additioaial sheet if necessary to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I arTt a home owner performing all the work home ...� �,.�, >�, G cue .;u� work 111yaeif.
.tv c,., _ ',;11-in M.._
NOTE: ply tat min thrt �s�- _�- �,,.E; w.s c;:i„ �w Ir� to do rra�.,<�xn cons:sucuoa ca- repair wow on a dwelling of
not mom than thme units in which the home—v — radde or on e..b groen ,.. ar ant tti& ;, arc, nix.' geno Ji.y c/= u to tie
employs nail= the worka's comvit Act (0L152; s! (5)), appfrton by a bom for a iic, or permit may evtdcncw .
;ear rintue of an erryloyer tind.arttee Woo'. 'a Cocer9entation Ac
I umterstand that a copy of this antem may be fozwar kd to t i Dq34.rizo,ond of I.daaaxriai Accickasti Leo of Insurance for the
coverage vu ificaiioe and that failure to E co tra , rf syr sow 25A of MOL 152 can lead to the imposition of criminal penalties
conisting of a fine of up to $1,500.04 ardor impr onnie! t of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.40 a day against tom.
s
Signed this ' day of / I e /i r&1 t 1 For deprrtrneatel ua only
I
/7 Permit Number
, i i i c -,! e' t - 1 /- : - = 6 l Map# Lot
Sigat e of 1 0wu eciPeiTuiiircc 1 1
... 1.f0 oi
Office of Consumer Affairs Sz. Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
fr
, ---,----- Registration: :105543
: - Type:
Private Corporation Office of Consumer Affairs and Business Regulation
:-Expiration 7/17/2012
10 Park Plan - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT:INC.
--.,-- -,---- -
Nelson Shifflett ..- - ' -
17
Northampton, MA 01060 / ,..V
340 RiversideDr. •,, . , -: : : ;, - .z :,- - ,-,- : :.: . ,,,„.,..,_______„,,,,,,,
:.--;--,, -
Undersecretary Nyyvalid without signature
A3assachuNetts - f) of 1 ''
Vg Bo lni of Buildin2 Regtill!tionsi um! Stanthirth
4 e '
On- : Two- Fsomdy .1J-.'
4 1 icE:ose: CS 6b300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062 -.
---__: ----- _------ __...-- -
y- ,...-. ErE 9/22/2012
...---
- .
.
r - �
| SECTION O' CONSTRUCTION SERVICES
J Licensed Construction Supervisor: Not Applicable O
Name o/ License Holder : -]Nelson Shifflett 060300
! Valley Home Improvement, Inc. uron`ewvnnh*r
'
340 Riverside Drive, Northampton, »«» 0I060_ 9/33 -__
Address | Expimz .
584-7522
----- --- ------- ----- ----� i
S :8natue Telephone i
� �
_ __ _ ^ � __-- _-___-__-- ___. ___ ___ ���
9^� qe�isto/e6�D��T ^ 'rove ��t��n\raot�� i No��p�|.cob.e O
Valley Home Impro o~______ _ --__ _IO [
Com:amyName Registration Number
34 Riverside Drive _' - 7/17/1Z '
Acdrmss i Expiration Date '
| Northampton, MA 01060 __�Ta(upkon 584�7522 ! _______ |
. — - ---- ��
_
SECTION 1.O- WORKERS'
_ ` --
Workers Compensation Insurance affidavit must be completed and submitted with |t|sapp|icotion, Failure to provide this fficl
will result in the denial of the issuance of the building permit _ ___ ___
I Signed Affidavit Attached Yes 0U No O |
The current exemption for "homeowners was extended to include Owner-occupied DiveIlirts olone (1) or z
` and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner ads
pa supervisor. CMQ78V. Sixth Edition Section {88.3,5.}.
Definition of Homeowner: Person (s) who own a parcel n[ land ouwhich hc:she resides or intends to rq,i6e. 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
st..uctures. A person who constructs niore than one home in a two-iiicar period shalt not hcc000ii_!ered a hy/poorac.i
3omh^`6omcn*ocr'sba|}submit/oUhcBuUdin!Officioiouu/ormuonrpmh|r|odhoDuUd(ngOffic|u|. tla! heishe shall lie
responsible for u|| such work performed uo4mrth«bg0diiIi1
AS acting Construction Supervisor your presence on the job site will be required from time tw/ino.durb'guodupon
completion of the work for which this permit is issucd.
Also be advised rhat with reference to Chapter 152 (Worhers' Compensation) and Chapter 153 (Liability of Employers to
8mp!oyees for injoricy not, resulting, in Dcet,) of the >4uecchusrrrG~neei |a^s Annotated. von o`mv )isb�i
\za�irz�o pc,f,c,,norLil'ryau:s( - 1cr:|iis pcnnic
The ondersi2ncd~bomuowou.^c::ii',csamJ assumes rex�xxUhUty for cmn1; with the S�:.:Bu]din�Cn��Cro�
Nnohnnnpr"a in000m, Xmwnnd["rn|7nnin?/lx , undStmrn[\{n
Hmmr*vocrSignutorc
°
_,C ka..w,_ ,, t C F t�� � �r,3 s K if i h r € , � � r , Ee'
ttl. , tEt Fs_> fE + !tier > A'ir dzwL A . :A40.}
cit
F `
if filer, hou..; _zt oraddition to exiting _housi w._compLcww thca
•
�Q� 5 / �
E :` : U 7 1:417F AUTt i bZAT;'C r O " E CO" . „C t ED ` iEN
ovaiEi'sa ACCNT OR CONTRACTOR ,* R i.i7b FOP 3C. fk D M PrRMIT
' . .s .,. Nelson Shiflett, Valley Home Improvement, Inc.
` ail ey__lHoraed_ Iriproyex en t, Inc F E
: F ora ` ., '' .
S e
Nel S }itt= `ret.{
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
r
Lot Size &'Oa -S)" 6 S
—
Frontage (o U 0
Setbacks Front � ' a' '
Side L: off R: / L:0) : /O
Rear d q ° 0
Building Height
Bldg. Square Footage 9 901 8 % / /0
v ,
Open Space Footage
(Lot area minus bldg & paved id t� ^� 7 f / / LO u 772,
parking)
/ {T
# 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 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
W 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 L/
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:
ir--. ,,,i, t ,„„
.......,..„.,::„.
..,„.
f
• I
)61 70 cr-D.Y ',..1
,
-
.. ._ _... ,
C Department use °Ili
City of Northampton
, c P
Status of Permit:
1-.-
6 0 . uilding Department Curb Cut/Driveway Permit
, • 1„. -
‘
% 212 Main Street Se,wer/Sootic Availabifity
, , 1
\ ' Room 100 Wa tertivieli Availability ' I
101 Tw
, ,..-s4,:: • .tnpton, MA 01060 ,
Two Sets of Structural Plans
..„ Fax 413-5874272 Plot/Site Plansi___
' l
Other Specify
.. - ICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i
,2 c.v (2 -
SECTION 1 - SITE INFORMATION
This section to be completed by office
1 1.3_ Properly Address:
Map Lot , Unit
l ------- '-.---
( W-oinvA......... Zone Overlay District
,
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
,--- - :
2.1 Owner of Record:
, q/ ithel ,6C 4/ _
Name (P ;Pt) urrewt ,1 lirui A '.
, 7 0
c _ 0 . 2.._,e3
, --,,-....,._•'' --_:L__7,,e__i_-_C---( TelEpho,ne
I Sigr!at s... '
r ,
2_2 Authorized keent: Nelson Shifflett
Valley Home Ipprovement, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) Current Marnng Andress.:
4■1/ Ae .....i 584-7522
i Sigru Te:taphorle ..... .
. 4 .
■
i :SECTION 3 - ESTIMATED CONSTRUCTION COSTS T
_..
.
,
,ten
I ' Tr.sitimale.a 0.0s (1. Tr.; be i
OF, L .,c Cr
co oy permit applicant. iciLi H:4
i 1. Building (a) Buikiirg Permit Pe
1 Yeci D
2. Eectrical (b) Estimated Total Cost of
Construction from (6)
1--- - ,
1 1 2 ±_in - Ityng 1 Building Permit Fee
: — ---1
4. 1ecnarlica (HVAC) i 1
, I .
2 ug
-..,' 3 - i - 4 a 5) i X‘44/ I Check Number
This Section For Official Use Only
Rdikting Permit Number: 1 DEte issued: - I 1
1
Signature,: .
' ':f. 1
,..,— , .„... _.. ,
File # BP- 2011 -0925
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC a0 VC 9
ADDRESS. /PHONE P 0 Box 60627 FLORENCE (413) 584 -7522 .
PROPERTY LOCATION 242 PROSPECT ST
MAP 24D PARCEL 226 001 ZONE URB(100)/ J - E
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST i$—
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ta
Fee Paid
Building Permit Filled out
Fee Paid 03teg / 2) 0
7� V--)
Typeof Construction: CONSTRUCT 9 X 1'2 DECK 20 1 /2..6Z. SE E f #
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
INFO4MATION PRESENTED:
LA'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
C/1 ( I
Signature of Building icial 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.
242 PROSPECT ST BP- 2011 -0925
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 226 CITY OF NORTHAMPTON
Lot: -001 PERSONS CON I'RACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit # BP- 2011 -0925
Project # JS- 2011- 001510
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 5706.36 Owner: BEDELL ELIZABETH
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 242 PROSPECT ST
Applicant Address: Phone: Insurance:
P 0 Box 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:5/12/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 9 X 1'2 DECK - 20' REAR SETBACK
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 5/12/2011 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner