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- DEPARTMENT OF BUILDING INSPECTIONS
. , ..4.3,........0 ,:*
212 Main Street ' Municipal Building ..-:-....,...• •
Northampton, Mass. 01060
WORKER'S CO ir ENSATION 2iSTLIRANCE AFFIDAVIT
,/ / f"
(licensetipermittte)
with a principal place of bnsiness/residence at: •
3 , :t 0 l ei /z i 2 / ) J /v6(._ , 0,/ (phoneft) , 584,4,- , -,7 - 2 - ,2
_
(g/tr —.t.kit. PI:zip)
do hereby certify, under the pains and penalties of perjury, that:
(>0 1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
) ,,ti C Z6 , 6 53 i :2/ /,///
(Insurance Company) (Policy Number) (Expiration Date)
( ) 1 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) (Lnsurance Company/Polic,y Numlx-r) (Expiration Date)
(Name of Contractor) (insulan Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lasarance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E:44)ira,fion Date)
(attach additicznal abaci ifriecrafAary to include inkrunation pt tb all wz!bra..rs)
( ) I MD a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: 1:,/-are b war .t: thd While) 1.10ZOZDVMZ who oziploy p-teaona to do mninr,, =an nrilion or revair work on a chaellina of
not more then theta unitg int bithtb intlYILL. rdr.3 Of OM the gray RA'S ani-- th,:r.nato are not gall-a:ally considered to b
amp tor= undet= the worie&F co=jef: no Act (GL152„sa 1 (5)) aNVii--„fion Ty a h on.., L. for a 11‹>--- t Is,- ntay evili tho-
len! sttus. of an -et2loya: endea- the Woft.a-f's C,oropa-.2eatito Att
1 „,.,!...,,,, „d t h,,, .„, ,--py of this , --- . 3 4,- - 1,..t rally b.:1 .t to CET Du- oot.mt of In.--tui used iss..,... Office of lo:v-L=T-L facli-
c.ove,---.E,; wrifiwics and that faihze to aceeart; , tm&i e:xxica 25.A. of lvtGL 152 c !d to tha inapnaM'on of aiminal pnaI6,m
now.i...ir of a fine of up to ,S1,500.(10 andfcIptofuptoytddvj1pflie s in the form of a Stop Wade. ord_,, sod a
ftne of 5100.0Ci a thy agaim meL
"
Si this ) clay of / ,-../) ,!:;/. g F.T. dti/artntood use only
Permit Numb / ft .i ti I - ' . 1.
Ma p# T - 0t. #
, _
■7.1671141.4-Lire lii 140: - ZIS e e. I? erraraee
AMP
•
14-p.1r of Itttitlit' ts.ttkl:t
, i t s ,t
t. tttitfltt ottottittu t‘etLtittttottot „Mu t...
COrist“...tctioct
Lc ti.nttott C5 60300
Rstr'tiitert 1G
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX606 27
FLORENCE, MA 01062
9,.222010
t t.ttotti,-topt
T r t: 3435
t`tt Board of it ttildinq btegottftts :tad Stotodirdi
Litaarse or registration valid for iudivii1o1 use on t)
. , .
HOME IMPROVEMENT CONTRACTOR before the ezpiration (late, 11 found return to:
Registration: 103 Board of Iluilding Regulat Stan
ions and dards
. One Ashburton flack: Rm. 130
ExPirationt 7;1712010 T 270
.i Vtir. 02108
Type : If] COr
VAL: fit
fq 8htttitt:tt --;:91;) 47./
Northampton, t.`A. 01C!"-"A AdmitiktrIlor 'tint s,11110ithoot NilovAim'e
. . . .
-- |
| ' CONSTRUCTION SERVICES
^1 J Licensed Construction Supervisor: Not Applicable O
Name of License Holder : Nelson Shif 'f Iett_ -__ _ - _' _----__-
Valley Home Improvement, Inc. uCvnsoHvmbm
340 Riverside Drive, Nor tb .0.1060. __ 9 / 22 /i 0 ---------
D
� Adurzo | �q.imUon vtv
584-7523
:-:;„?.;nature [e|cphnn:
---- ---- - ------- -------- �--� -- ---- ----
) ReEistered Home Improvement Contractor: '` . | NntAppFcab O �
Valley , Inc_ 10554 3___ __�
Company Name Registration Number
340 Riverside Drive _ .7/17'10
ExoiraUonDa�c
Northampton. D�� 01060 � h" 5Q� |
u������" �oe no_����_ .
SECTION I0 INSURANCE AFFADANT(�0.G � �S�(�
'Workers Compensation Insurance affidavit must be and submitted with this failure to pczidathbaridavi\
�u/"� ox �
will result �n the denial of issuance of bui(din� permit,
Signc.id,AffidavtAttached Yes OB No
Tk� cos'eot exemption for "homeowners" mas�xzu`dcd to include Owxer-oo^xpad n[000(D at o0n
and to allmv such homeowner to engage an individual for hire who does not possess a license, provided the RctS
2S L slwcrpiso: 780. Sixth Edition Section 108.3.5.1
Definition of Homeowner Person (5) who own a parcel or land on which heishe resides or intends to reside, wnwhicbthere
or is tciido.d 10 ho, a one or iwo fiunilv dveUino. attLlehed or r1euchcd s1ructures accersory 10 such end: or
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Buildinf! Official, that 1 .jc/ 0 4 , ;:. ����b�
for suet rvorL�e under 1hc t:i���oe
As acting Construction Supervisor your presence on the job site will be required From time to time, durinu, and upon
completion of the work for which this permit ixissued.
Also 6o advised that with reference uzChapter 152(\Vn,ton'Co.upcnux/nn) and Chapter 153(LiztbOity
Employees for injuries not resulting. in Dm1b)of the MussvcbnurnsCicnem| laws Annotated voiimayha >teVno*c(w
youh�ra pc/ �rk|�t yttu u��dcrd�ip�csni�
Thcuadeoi2fled '1mmc certifies and assumes nzpuxsibUityibr with the or
Northampton Ordinances, Statc and Local Zoning and State n{ Massachusetts General lans Annoutod,
L10soovro:i* ���*"/�rc_�____�
ty)74
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Section 4.
ALL INFORMATION I JST 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
p p
(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 1/ DON'T KNOW YES
W YES, date issued:
W YES: Was the permit recorded at the Registry of Deeds? /
NO / DON'T KNOW YES
DE=
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
IF YES, describe size, t'y'pe cu uu 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:
I - uepartment use on:y
t , -
City of Northampton Status or Porrrnt:
. ,
1 • .
,-- .... . _BOilding Department !Cu: b Cut/Drivei:vay:Permit __• ___- - 1
, v „ - .- cs 21 Main Street Sewer/Septic Availability
,--------- '-l-- 100 Waler/WelI Ayai:abi*
* -
:N.tirm,th MA 01060 TwOISets of -Structural Plans
phone 4-1*3 P
-587-1240 Fax 413-587-1272 _ .,,
lot/Site Hans - . • . .
. „ ... . .
Othei' Spec:6' .- ., ; - • -- - . - - r ' ..
-■■■ ...M.
--, APPLICATION TO CONSTRUCT, ALTE7R, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY --..)WELLING I
.---
' SECTION 1 - SITE INFORMATION
1
______ _
Thissection to be completed by office
1.1 Pvoperty, Address:
lib OV4rkok .,,,brrve_. Map ___ _ Lot Unit
./ ore nce A 01 0 (4) )- Zone Overlay DIstvict __ _
Elm Et. Dittrict CB District
_ —
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1 r (/ j A.4...s3 / 4./ t 044 071.4., 4.i' 1
2.1_Owner of Record: /U0 ,&ii e r7: 144 ' 40 1
I Jane lien ders 0 4/6, overioOk.:. Dr Florence__
Name (Fri') Current 49Hin4 Address:
- i
/ , VL —
1 .. / 24. Telephone 1
1 ,--=.- .-i •
---1 p,„sn,LIe
2„2 Authorized Agent: Nelson Shifflett
[
Valloy Home ipprovement, Inc. P.O. Box 60627, Tici. 524U2
Name C rnI) ClIrrent N P.(Aress: I
14
I : P ,, 584-752" I
:--;I ' ' Te:ophone
C SITCTRIIK 3 - ESTIMATED CONSTRLICTICM COSTS
. !
1 item c_sUy.aled COST. =,U0i4 ,i - ,c; L;;. i ''..i.._..;,- LIIE,0 0[4
-- copleted 1 pci`mit applicant
m
1 1.. BuAin 2 (..;) Building Perrnit Fe'J
I ,
_____
--1- —
1 2 Fleetrlc::::?fl 1(1)) Estimated Total Cost of 1
I : Construction from (6)
.,...___.
. ::-"I.Irribing 112tnirli:lg
Pert Fee ■
1 ■
—
4. M -1
echani.eal (I-1VAC) .,--- I
1 6 TotaI - 1 "1 2 + 3 + 4 + b) 1 I 1 CI;€,c,K Number . 70 q __It tC. ■
— - -- — _
_____ ,____ _..„. _____________. __ _____,
i 1
ir, F-ermit Nure__ _ Date I,ssued
1
I ,,-- •
BuIldint Ccrrirlissiumr/Inspector c: DLIICings
F-. te ,
File # BP- 2010 -1201
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 46 OVERLOOK DR
MAP 29 PARCEL 194 001 ZONE URA(100) //WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
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
INF, O 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
1 �
6/240
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.
P.146 OVERLOOK BP- 2010 -1201
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 194 : 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 -1201
Project # JS- 2010- 001735
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft): 15986.52 Owner: HENDERSON WILLIAM A JR & JANE
Zoning: URA(100) //WSP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 46 OVERLOOK DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON: 6/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 6/29/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo