31A-149 WNW
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rip DEPARTMENT OF BUILDING INSPECTIONS .._
NSPECTIONS ..: .
212 Main Street • Municipal Building ' '�•. �• '
• Northampton, Mass. 01060 us 5
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
•
I, WV 1-50Ar sly //'/=:-"4-6-77 VM-I- r 7--3-7/ -a fir , 7i,.231 c
(license&Jpermittee)
with a principal place of business/residence at:
.3 go l ei /z,65 4 68. 8. z )ni/ it 0,e/2f ,i ; Ind (phone #) ✓`' 8 (/- 77ZZ.
(st ticity!staiJrip) / /06 v
do hereby certify, under the pains and penalties of perjury, that:
1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
Acadia Insurance Company WCA5029908 2/1/2013 " ,
(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 sleet if necessary to include information pertaining to all contractors)
( ) 1 at a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do maintenance, ce wmuvciion or repair work on a dwelling of
not mare than three units in wbicit the homeowner resides or ca the grounds appurtenant thereto are not generally coosidcred to be
employers under the worker's compensation Act (GL152,s 1(5)), application by a homeowner fora license or permit may evidence the
legal status of an employer under the Worker's Compensation Act_
I understand that a copy of this statement may be forwarded to the Department of Industrial A ciderni Office of Insurance for the
coverage verification and that failure to secure coverages under section. ion. 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form ofa Stop Work order and a
fine of 5100A0 a day against me.
Signed this / $ day of / 20/Z. For � only
6 ,'"1-' Permit Number •
1 ' •ij . Map# Lot #
Signature of Lf ... • ermittee
0 - ifazwritoluveald alf
Office. of. Consumer Affairs & Business Regulation License or registration valid for individu) use only .
_ _ - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 105543 Type: Office of Consumer Affairs and Business Regulation
' l= xpiration;._ 7/17 /2012 Private Corporation 10 Park Plaza - Suite 5170
Boston, MA 02116
VALLEY HOME IMPROVEMENT:INC.
Nelson Shifflett
340 Rivers ideDr. ' 4_ t� ff ` �
Northampton, MA 01060 ... Undersecretar II" A 9
y NI,° alid without signature
r
Massachusetts - Department of Public Safct■
V4. C
Board of Buildin Rc!uulations and Standards
Construction Supervisor License
One- and Two- Family Dwellings
License: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627 k •
FLORENCE, MA 01062
°%----- ___.-- -� Expiration: 9/22/2012
( , nmiissiuncr• Tr #: 2383
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shif fie tt 060300
Valley Home Improvement, Inc. License Number
340 Riverside Dri - +• . -“. .. ut s 1.1 9 /22//2
Address Expiration Date
584 - 7522
Signature Telephone
1 2/4
9. Reis - r - • Im.rove t -n .ntract•r- Not Applicable ❑
Val ley Home Improvement, Tnc_ 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 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 SI No 0
11. - Home Owner Exemption
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 hefshe 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 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
!
..c.CTION 5. DESCRIPTION OF PROPOSED WORK (check ell opplichic)
... ....._
New House :.:1 I Addition LI Replacement Windows ` Alteration(s) C Rooting ID
07 Doors
Accessory Bldg. ° Demolition° New Signs " 1 Decks ' ) Siding [ 1 Other>d
I
Dc..:c.i....)". on ;;;.! PR ixp,ea t'imo-14, atepla ,60AilYN -- Pre 10) e fv-rtAscrebof itpa. e.by . 44i-
,
irti., nti(:on't YPe, sl/<t. r",f;f1 np, rw opritrtc-r 't pci
Att'ec't)uLf ',hart ,:ttivf,:' !.%,•e-f , ..iftioe.,,htt.d t.;',0 l'e.,:. /...../tlu
.." r..:
tr„zhet Rol: ,..-
6a. If New house and or addition to existing housing, complete the following:
off,Icatir , C 7 arn k. Two 7 ,11rulv
' t; l',.mrziel i".' each •arti:y ert,I1 Vertf f)t :riatEVCd1',E,
L,
j r r e;):) St;Oor t: ti. +;r: 11!"VA ,;(, tRICt :)11
.)I'' ew.K.
...' N,r °f , ..f. ,- ftip;Y 4) /fi
t. Vethod ut heatAli,-;:' F r ti; •octe. uf Wucdt. Nut V ttoch
E-,pry Ce t r Erictgy Cornoll forth 8:tact cc?
1. °I cc f•ttu..itrCi _ .. _.
'..z.Ctr...;,:lK. w,tiii 1 1 O) 1 '.:.rt v. et',:::IG. f,? Yes N.I.; Is cur Istrocl11 w,11Iii 100 vi *Ic:
:
, Dt-i :-.4 :1;, celi;:sr 1,toor oplo..,0 'inr„hpct afact:e.
'..)ti Idir::: ^.:C* tbr 7 to the 1.31itidthp, and 2.'orli,r)F: Rfit;.;latic f„? Ye.:',...._ 1
i
C Z.. Sewf7r Pr ..ri3:,':,' %%el f;Ity v Sp y
SECTION 7a - OWNER AUTHORIZATION - TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
WO 1 f
, ,, , af.., Owner ct t 1,uct pfDpefti
. Nelson Shi Iflett, Valley, Home Improvement, ,Inc .
my ...., t „,if ,, -lee .f.:, , .::,-, , t1T:e IF, rmk c t,i this, l'..t.,x f'; rei7. - _,)tter- ft a plicitt ,,
i
/
sto-,.B.Jr- of Owner
Nelson _Sh ill le t t, Vail ey_kloxle—ilipromement , Inc, „1 :1'..vnt'llAtIln:Yt7itl P.Ef7rt!
hr'r.by disc' nrc. ;,` •. ...;taterncl t...trici inforrqthDri ryst the foreKorr kz. iror2. ,;le /. ortd ili:u_vr:lte, h.r lie Lst-,,t el n'y
t-.1 c.-/Jecge End belici.
4., ..y d r._ and r: /,:fief trcti u' puti./y
Nelson Shif f let t_ _ ____
....„
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Jr ce, ::,,,--te,,
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 Building Height
700
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 rmit 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:
�c�t 3 hdu4A � � - �r� /n� �� <-G1 s^ 1��
Department use only
\ � ity of Northampton Status of Perr
r \`� , ` Building Department Curb Cut /DrivewayP emit
' 0 212 Main Street Sewer /Septic ailability
E Av
Room 100 '+ / We ll Availability A s
� .Gua ... , "!7 g a s r
, t~ t - --�- Northam MA 01060 T Set o f §tNctural Plans ��
V Nom `s P �
\ Fax 413. 587 - 1272 Plot /Site P 4 ari,W � �;
Other Specif k
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
j 5 /)(9 yN iv c) J' T- . Map Lot Unit
Nd 1 ` A PYI i ikar-) Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
J .. 0 i C- 1 0sk. ill
Name ► / r Current Mailing Address: M
/ i / v Telephone
Sig
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address:
7) 584 -7522 _ _
Signature T elephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building l5;00° (a) Building Permit Fee
2. Electrical S003r9 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing /0 �t, Building Permit Fee
i
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 3.6 pQa Check Number ...) 41/39 i / 0
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: —
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0149
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 15 MAYNARD RD
MAP 31A PARCEL 149 001 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 { \
Fee Paid <5
Typeof Construction:_REMODEL BATH,REPLACE PORCH SCREENS & POSTS,RECONFIGURE CLOSET
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / ' . Plan
THE FOL . • WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO t : ATION PRESENTED:
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
Peinut from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
olition -
e of B: ilding 0 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.
15 MAYNARD RD BP-2013-0149
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 149 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0149
Project # JS- 2013- 000246
Est. Cost: $30000.00
Fee: $180.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 10628.64 Owner: DAVID JUSTIN & JUDITH WOLF
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 15 MAYNARD RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 - 7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:8/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH,REPLACE PORCH SCREENS &
POSTS,RECONFIGURE CLOSET
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 8/13/2012 0:00:00 $180.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner