31B-054 ,
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`�'W : DEPARTMENT OF BUILDING INSPECTIONS , _ t
ili
j
212 Main Street Municipal Building , —
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A ek'!i)AVIT
L Al2 t-Saitr s// it =/=z_-L 1 V f /fDilLell ,/---- Art i , l c_
(licenseeipermittee)
with a principal place of business/residence at:
•
3 `fo ,i/f 5 Lb 2- v /z f f,6021 ,#7,2 gill (phone #) . 6 1 e/- 7
(street/city!s to rip) 4 /0b U
do hereby certify, under the pains and penalties of perjury, that:
(X I am an employer providing the following worker's compensation coverage for my
employees working on this job:
/e2:42'55' .Li% Gtr - G ,76, O 55 o 1 2 /i //i) _
(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 shed 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 while homeowners who employ persona to do u iaten ___a construction 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 cooauiered to be
employers under the worker's campeasatica Ad (GL152,ss l (5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worms Compensation Ad.
I understand that a copy of this statement may be forwarded to the Depertmwt of Industrial Aeeideab' 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 fete 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 5100.00 a day against tae.
r
Signed this / day of �` G l 2 ' For departmental use only
Permit Number
. ► - 4 Map# it #
Signature; of LL...:- • ermittee
NI,H,.ichttNo Ht ' al'tt‘
I3oao`tl Aat !`ttaltli €it4 Ir't OIattrYos \t,
f.onstructean S.ut !.. rrt'5er ; ICer e:
L €cats ,e CS 60300
Rest €wien tU, 1
NELSON A SHIFFLETT
340 RIVERSIDE DR PHX60627
FLORENCE, MA 01062
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1303rd of Building RegoIastions and Standards I..itense or registration r alit) for inditi ialul use outs'
l HOME IMPROVEMENT CONTRACTOR before the espiratinn date. If found return to
Registration: 105543 Board of Building Regulations and Standards
One Ashburton Place Run 1301
Expiration: 7117/2010 Tr# 27046 Boston, 41a. 02108
Type: Private Corparat on
VALLEY HOME I IPROVEMENT INC
P! Hoar SHfflott '2:1(1 , r
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343 €`'�1k £sfSl fJ� a a-' N Lf P f 7,714,/,/
^ �_, ;I�rtr.;;at .n htA. 1 1tlmirtlstr stYr€
Not s "Ali s� Ithout signature
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shiff let t__ 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA 010._60 9/22/10 __
Address Expiration Date
584 - 7522
Signature Telephone
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•
9. Registered Ho , ' Im►rovement Contractor: Not Applicab e ❑
Valley Home Improvement, Inc. _ 105543
Company Name Registration Number
340 Riverside Drive 7/17 .
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 ❑
11. H me Owner Exern pt on
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 he
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 tune, 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
• - tz..c.Tr0N 5. DESCRIPTION OF PROPOSED WORK (sbm.k .1,11
Now ficime S'‘. Addition L.1 Replacement Windows Xteration() Roofing
Or Doors
Accessory Bldg. U Demclitior U New Signs " I Decks ' Sidirg Other kr
3 » r Apie-CesiffLci (
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6. If New house and or addition to existinl housing, complete the following:
ratYLI.,
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; ; ;77 C•arT f0r14 ,0".tilt7:1 Le",
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N Ui t 411 V, I IOU yi
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SECTION 7 - OWNER AUTHORIZATION - TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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Nelson Shifflett, Valley Horne Improvement, Inc.
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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: L: R:
t 4
Rear
Building Height /t
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: ermyl4'JJ
IF YES: Was the P Registry at the Re istry 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
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:
. w
Department use only
City of Northampton Status of Permi
ri-OU Building Department Curb Ceway P er mi t
212 Main Street
Sewer /Septic v v Availabty
' Room 100 �Nater /Well ut /Driv Availab
Northampton, MA 01060 Two' Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot /Site Plans
Other Specify
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
3/ 20,3 LO° (V11) Map Lot Unit
/ d„ Zone _ Overlay District
Elm St. District,. CB District_
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1, caner of Record: /�� /J
LJ AJ t J L � � �� H / (�11 f�1 � , d ,6C /1 `
Name nnt} Current Mailing Address:
�1/�,, Telephone
Signature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc, P.O. Box 60627, Florence, Mid 01062
Name (Print) Current Mailing Address:
- / q • 584- 7522
Signature / ' Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant —
3. Building Y-4-2 d (a) Building Permit Fee
2. Electrical , (b) Estimated Total Cost of
:5-0C) Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) l( a 0 Check Number ,✓ 9 c--
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date —_
•
File # BP- 2010 -0654
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 31 LANGWORTHY RD
MAP 31B PARCEL 054 001 ZONE URA(95)/URC(5)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
�J C
Typeof Construction: REPLACE UPPER CABINETS & NEW LIGHTING
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF A TION PRESENTED:
p proved Additional pe rmits 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
,'1711r ___//1/7/_____ „
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.
•
.I , 0*WOtTY RD BP- 2010 -0654
GIS #: COMMONWEALTH OF MASSACHUSETTS
054 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 -0654
Project # JS- 2010 - 000950
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.): 6708.24 Owner: ROBERTSON CHARLES L & DENISE ROCHAT
Zoning: URA(95)/URC(5)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 31 LANGWORTHY RD
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:1/12/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE UPPER CABINETS & NEW LIGHTING
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 1/12/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo