31A-282 (2) cttAMp
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` DEPARTMENT OP BUILDITNG I_NSPECTIONS
• . 212 Main Street • Municipal Building ' _
1y = "V
Northampton, Mass. 01060
WORKER'S COMPENSATION IiSURANCE AFFIDAVIT
I, �� L.-5 6 S / f =L , ° v://-z_, ' /to:-it . .,�% - - 7'i / ^e `./Ls, -7i, t (._
(l.icensee/permittee)
with a principal place of business/residence at:
3 -to /0 / Z/65 i.b _ i)itik , //D --/7/, Vi2 /J ,? (phone #) � `f 7 ZZ._
(st a+. e/cip) 1 /Oe' 0
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
, S Z , �.e»' L - i f S , G c ) . 4,0 e ;766' 55 oo ! 2/ / ///
(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)
( additional sheet ifnrrrrcaiy to include information pertaining to all contractors)
( ) I a.m. 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 vilzilo homem,vners who employ persons to do maintrnar , wasuuction repair work on a dwelling of
not more than three units in which the homeowner mcid s or on the grounds appurtenant thereto are not generally considered to be
employers under the workees ■etina Act (GL152,sa 1(5)), appli^-ation by a homeowner for a lime or permit may evidence the
legal status of an employer under the Worm's Compensation. Act.
I understand that a copy of this st may be forwarded to the Department of Industrial Aoc ideQM 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 fine of up to S1,5OO.0O and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against m:..
Signed this day of /7,/,/
tfi' 6 For departmental We only
Permit Number .
4 ,ie re' ' tr / lviapil Lot #
Signature of Lieensee/Permittee
, .
.../n.e loanvino/ruzieae'd, ol,./.,lia
_ - k-----N Office of Consumer AffUirs & Business Regulation License or registration valid for individul use only
:4 ------N-F -- - - --==--9 HOME IMPROVEMENT CONTRACTOR
:U" Registration: '105543 Type: Of
'. .r . .V.a_.=- f:. , ".,.Exoiration: 7/17/2012
Private Corporation before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT INC
Nelson Shifflett
,± `;..::::;;f•':: ::::::::::::-' '' ' -,79 ir , y y
,13 '
J .,
Northampton, MA 01060 :"' '. -
Undersecr .
,.., uersecrary e Nfivalid without signature
- Depiii if Pul;lic . ",af-,:',:,
g Board of Buildintz Regulation", and Standard \
C. ?"125 !.....,cen
One- and Two- Family Dwellings
License: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627 •
FLORENCE, MA 01062
E. 9/22/2012
....-----
( 0111111 iSSi"131.`l Tr* 2383
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder : Nelson Shif'let t_._ 060300
Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, mA 0i0,6 9 / 22 /0
Address Expiration Date
584-7522
gnat Telephone
9. Registered Home Improvement__tQontractor: i Not Ap,licab:e ❑
Valley _come Improvement, Inc_._. _ 105543
Company Name Registration Number
340 Riverside Drive 7/17 - /12
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 end submitted with this application. Failure to provide rhis ahicava
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
The current exemption for `homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(?) families
and to allow such homeowner to eni7age an individual for hire who does not possess a license, provided that the owner acts
as supervisor. Ci\'IR 730. 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 teriod 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 buildin" permit.
As a ctine, Construction Supervisor vour presened) on Me j ob site ill l.i: t..ij'i ed from ...., u.ia C% ui a ),1
completion ()Idle work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Emplo to
Employees for injuries not resulting in Death) of the Massachusetts General Law's Annotated, von 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
1`,1oilltamprion Ordinances, State and Local Zoning Laws oid State of Massachusetts General Laws Annotated,
t ton,eownei' Signature
7cTle.N ,
ALiditicri ReplaLeme..t A retie:NTT,
Duo-s
Accory Der11 Nev.. Signs I StCirC ' Othg-
/?e,
6 Ltly.
— —
if New house and or addition to existing housing . complete the following
. L..
" .
ki .; . A ,
SEC 7a OWNER AUTii0PIZATON - TO DE COMPLETED WilE14
OWNERS ,..s.,GC;T OR CONTRACTOR PHES FOP BUILDING PERMIT
shtilA Ettutti
Nelson Shiflett, Valley Home Improvement, Inc.
(geeLt-to 4 4 - aka 6 — 2:3- —ID
L =
N A elsoShl.ttlett., ,Home_.Inproyexoexit,
!! t'e! ! : „
Nelson Shi.trlett
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:
Rear N 1 /
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location) i —
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
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:
,..
/ete,i
e D c /c2t4) i
Department use only ---"
City of Northampton
Status of Permit:
Building Department Curb Cut/Driveway Permit
- ists),
', 212 Main Street •1.
S=wer/Septic Availaoiiity
Room 100 Water/Well Avallabi 1 y
-) 1- Northampton, MA 01060 Two ,.. ets 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
This section to be completed by office i
1.1 Property_Address:
(4.)U.41A) Ave-AU42,..._ Map _ Lot _Unit •
Zone Overlay District
_
1\) le • A.,A, ■ &Ca OkO ,
— ,
Elm St. District CI3 District _
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Silt- LL 5 f - e utt
Nana (Print) Curreekli;'1.9Acirsy.c..:
Telephone
Signat a
I 2.2 Aeent: Nelson Shifflett
I Valley Home Improvement, Ino. P.O. Box 60627, Florence„ MA 01062
i
Nam ° (Prin;) Current % ,A,..itess'
ii .L./4 4 ../iE■AY 584-7522
Signature / Te:c phone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS --[----
.... . _
Item 1 Est:mated Cost (Dollars) to be Oi", Use Only
completed a .,p1
Building (a) Building Perrn,t Foe
[ (b) Estimated Total Cost of
Construction from (6)_______
Building Permit Fee
(- MP(*) arl ICP 1 (HVAC)
J. t' re Protecuon
F 5 - 1 7- ota: =(1 + 2 .,-. 3 + 4 ± 5) .."r" J Chock Number , 5" , $
_ This Section For Official Use Only ______
E,Litining Permit Nurnbc:!r: _ Date Issued:
SIgnature: . .,, ,. ector o f Bt.:kings. Date
BlaCittla COMMISSIOnet I Ity,p . —
BP- 2011 -0401
pis #: COMMONWEALTH OF MASSACHUSETTS
:10, { 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- 2011 -0401
Project # JS- 2011- 000664
Est. Cost: $7500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 29098.08 Owner: KORFF JEFFREY M & STEUER SHELLY
Zoning: RR(11)/URA(89) //WP Applicant: VALLEY HOME IMPROVEMENT INC
AT: 100 WASHINGTON AVE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:10/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & TILE
SHOWER
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 10/28/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner