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WeSP f DEPARTMENT OF BUILDING INSPECTIONS 4
•‘ 212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION Dian AFFIDAVIT
//e)/72:. L_ ,,,47,%1-75/&;,,, 7c
' (licenset/permittee)
with a principal place of business/residence at:
3 -to K'.:///4-5 / :b 2 /),--11/2' "ae-i7tgin,7 "V/ (phone#) 1 58 . 7 4- • 72
( s i c i ty l stath i z i p ) z i,oz , 0
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:
55 / 2/64/
(Insurance Company) (Policy Number) (ExTiiration 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)
(attath adcliticasal shed if necessary to include information pertaining to all contractors)
( ) 1 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 persons to do msintmas construction or repair work on a dwelling of
not more than three units in which the homeowner reticles or on the grounds appurtenant theodo are not generally considered to be
employers under the worker's compensation Act (GL152,sa I (5)), application by a homeowner for a ticm-se or Ismail may eviticom the
legal status of an employer under the Worker's Compensation Act_
I und=stend thri a copy of this rtatetr -m may be Pa-warded to the Departnient of Inetustri ed AccidtTsts' OfEati of Insurance for the
coverage verification and that failure to secure covet under section 25A of MGL 152 can lead to the imposition °faint:coal penalties
coosisting of a the of up to S1,500.00 ending insprisormeat of up to one year and civil pcoalties in tbe form of a Stop Work Codex and a
fine of 5100.00 a clay Egainat tot,
Signed this "? l° day of 7,71) .,,,,,,y/. 0 For departments! use only
Permit Number
% i dfe z 7-. - fi
‘4 .64, t V4 ',ad Niall Lot 4
/
Signature of Ete ermittee t 1
I;tft Htlf,Httnent 01 Pu
)V guard Borislitut ‘",,i.itid,“
t.,rorisrszil—ion
t-mci C 60300
Pe strir led to I $1.
NELSON A SHIFFLETT
340 RIVERS(DE DR P8X60627
FLORENCE, MA 01062
9/22=2010
rit 3435
Bnard or Building BeglitaiiitUs' Arad Standur License or registration valid for indiN nits) use mil)
HOME IMPROVEMENT CONTRACTOR before thy etpiration (tate. 11 found return to
1. Registration: -105543 Board of Building Regulations and Standards
One Ashburton Place Rat 131H
Expiration: 7117'2010 Tr# 270246
Boston, NI a, 0210
Type: Pryate Corpordt,nt
VALLEY I iamE tt.-i:'rt()VEMENT
Ntt.18ort 81iffie ////'
et.ir ////
N LtA 01 Or.30 ‘drnini,tr. Nut s migN,ithotit ,ignmure
k
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Appicable ❑
Warne of License Holder : Nelson Shifflett_____ 060300
i Valley Home Improvement, Inc. Lccnsc Number
340 Riverside Drive, _N r_thamp_ton MA __0106.0. 9/22/
Address Expira p oi Date
584 -7522
Signature 1
3._ Registered Home Improvement_ Contractor: . Not AI _,I c al; e ❑
Valley .._ -Home Improv--ement, _Inc._ _ 105543
Company Name Registration Number
340 Riverside Drive 7/1 -- _
Address Expiration Date I
Northampton, MA 01060 T ;ophor. 5 84 - 7522
L SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.O.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 Xi No 1
IL - Home Owner Exemption
The current exemption for `'homeowners" was extended to include Owner - occupied Dwellings ol' (1) or two(2) ILiru ie:s
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. C1'IR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which hL 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 rind or farm
Sir OCT tires. ,Ai 13e ,Li tt iia constructs nuwe than one home in a Iwo-year eriod skid; in be .'onsit_e d a ', ;�u ,
Such "homeowner shall submit to the Building Official, on a form acceptable to the Building Official, thatthhc ishc shall he
responsible for all such Nvoik perforated under the I)ttildin ° permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the xvork for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability oh HIT [Oyer .ti t3
Employees for injuries not resulting, in Death) of Mtissachi setts General Laws Annotated, yore ¢ttav be liable lb oerson(s
you titre to perform work Tor you ludo this 'lei-init.
The undersigned "homeowner" certifies fies and assumes responsibility for compliance with the State Building Code Thy of
Northampton Ordinances, State and Local Zoning_ Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
nnor:os:r.r)
N1:w 11;:w.,t1 1,0.1iti(xt■ ,21ait_qttc',11,Airld; A ;.:1.1trt(L): Roc!rri;
COli;'f,
Acc,asscrry Ncvt Signs I Df. Slcirg 0411E,
d&esAy11 . 3 1/i .)11
1.
w.5101.. tie/i )/0..i 2°b Atf
•
6.t. If tidy* house znd or addition to eKisting hotisinR. cornpleteAlicial [awing.
/t)
- OWtittP AUTI «OMZAT,Cti 1'0 D CO%1PLETED Wi1E14
owNEPS itr.r.N:::'T OP CONTRACTCP PE US FOR nuttomn PrRmr
ioctvi irolA)n
Nelson Shitilett, Valley Horne Improvement, Inc.
/./
Nelson_Shitilatt, Valley Home _Improvement, Inc.
1
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:
Rear
—
Building Height
Bldg. Square Footage , yam
Open Space Footage / v
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Speci I 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:.
. ,
Department use orily
City of Northampton Status of Permit:
/ ,..7.N., Building Department Curb Cut/Driveway Permit _
/ c" •) / 212 Main Street Sewer/Septic Availability
c'D Room 100 Water/Well Availability
—
. ,
-a Northampton, MA 01060 Two Sets of Structural Plans
- N S - phone 413-5874240 Fax 413-587-1272 Plot/Site Plans_
/ f Other Specify
. ..._
A'PinICATION 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 offiC
6 7 tJe Fc Rd. Map ._ _ _ Lot _ . , _Unit__
Abr i to pia I Oto .0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHOR 1 IZED AGENT .---, _ 1 • . /
,....
2.1 Owner of Record: Aid Aneth 45 r7Vi-c-
lioll 1
51 wes-f I e_CI Al ample)?
Name (" IF
CurrentiaWng Ac_frkt-y
---
Teiephone
_ ------,..„........_.
S ignat UT
2.2 Aut ot ized Agent: Nelson Shifflett
Valle Home Improvement, Inc,. P.O. Box 60627, Flprence,_ NA 01062
_...._
Nino (P in Current Mailing ,A.cfcil-ass:
11 584-7522
Alf
;,,igrature Telephone
_ ...
Yig .
SECTION ' - ESTIMATED CONSTRUCTION COSTS
Item E.stima;,ed CosT. (.ioilars) :o loc l Otiti Usc Qr y
completed by oormit appliaan;
1 Biwiding (a) Building Perm.t Feo
— -I-
2. Eectrlcal (h) Estimated Total Cost of
3 HIJ
--i Construction from (6)
Building Permit Fe(-
4. Mechanical (I NAG) i
Protection 0
.4.61)2_,,,
.._ _
CD. T _ otal -7 (.1 + 2 + 3 + 4 + ___
5) 1 rjheCK NUMF ity g503 !
....,
t_
_ _
i This Section For Official Use Onl-- y . _
...
ding Permit Nuneber: Date IssueC::
„ _______ _
Signature:
_
Building Cernm ssionerllnsipector of F3uilci _
ings Date
__ -- - . ____
File # BP- 2010 -1200
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 51 WEST FARMS RD
MAP 35 PARCEL 010 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out '��
Fee Paid Q�/ a6 �
Tvpeof Construction: INSTALL REPLACEMENT WINDOWS & 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
INFQRMATION 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
/f/e. 6 /0/Vi0
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.
WEST FARMS R BP- 2010 -1200
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :B1ock:'35 - 010 ..: 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 -1200
Project # JS- 2010- 001734
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 24219.36 Owner: BROWN JODY R
Zoning: SR(100) //WSP II Applicant: VALLEY HOME IMPROVEMENT INC
AT: 51 WEST FARMS RD
Applicant Address: Phone: Insurance:
P 0 Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON :6/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS &
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