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Valley Home Improvement, Inc.
BOX 60627, NOVI'l LAWTON, MA 01062
413-584-7522
P.O. .
FAX 413-585-0820 DESIGN,/ BILILD
ADDITIONS • RENOVATIONS
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t'onfithintiality 1 privilege Notice: This transmission, including annebnients, is intended solely for the use of the designated recipient(s). Th:s
is ansnossion may contain information that is conthicntial and/or privileged or otherwise protected from disclosure. The use or disclosure of tits
mtbrrniitiOil contained in this transmission for any purpose other than that intended by its transmittal is strictly prohibited. If you are not an
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W } DEPA OP BUILDING INSPECTIONS '� •
212 Main Street ' Municipal Building -,
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
/ �/ ( L L 5 f� Ai Sid I Ti (// / 7- _ ,.7- / a`L.b? i , 27,1c
(Iicensee/permittee)
with a principal place of business/residence at:
•
3 ` f o / eh/Lie-5 / b ._ / )/411/Z A / D 2 1 7 1 ` A Z Y l i i i f l i f (phone #)_ 9 - 8 `f - %- ZZ
(strert/city!s of ;zip) diu )
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:
/ , (1Z 's' G //S, 0. t• ?66` 55 0 ! 2 /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 sheet 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 persons to do maintenance, constrwion or repair work on a dwelling of
not more than three units is which the homeowner resides or on the grounds appurtenant thescto are not generally considered to be
employers under the worker's dolt Act (GL152,ss1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this ssalrmmt may be forwarded to the Depart:1=d of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of WI. 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1, 500.00 and/or iraprisonmecd 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 tux.
Signed this � day of /T f i 0 For deparmsental use only
4
i/i rl i i / 1 7 , zi /-/ Permit Number
Siglar.uIc ox L tenseefPermittee
•
. .
* .
14. ,
hi0
tSt•'■ ''- DA, li.trtment , d Public ‘stivi:‘
t 4 5 Ilii:drd 01 Hin lifin.2 Iteg,tiLitlinis and '
.0.
‘...,..,...e. Constzuction Sup T License
Li-cense, CS 60300 I
Restricted to 1G
NELSON A SHIFFLETT ,
..„,
340 RIVERSIDE DR P8X60627
T
FLORENCE, MA01062
,,4 ,.....„,-, Exou 9.2212010
4 .1 .akii, r T r" 3435
''2 - -- e 1 , '''''' ; i
.. f in.,,),- 7 ,, a ,1,,e. ,i, .1.,
.,-;\ Nan! of Building Beguleions and Standards Licoise or registration valid for individul use Only
HOME IMPROVEMENT CONTRACTOR before the etpiration date. If found return to:
Registration; 105543 Board of Building Regulations and Standards
One ANIiburton Place R 1301
Expiration= 7i17/2010 Tr# 270246
Boston, Ma. 02108
Type: Private Corporabon
VALLEY HOME it.APROVEMENT iNC
„...-
Nelson ShifilOt 71
ii /2
WrthampTon MA 01060 Adminisit4ttor Not N all, : 4 Mout signature
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder : Nelson Shif filet _- — 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA 0.106 9/22/f
Address Expiration Date
584 -7522
Signature Telephone
9. Registered Rprne lmprovement Contractor: : Net A of cabre ❑
Valley_ Home Improvement, Inc.._ 105543
Company Name Registration Number
340 Riverside Drive
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 )g1 No 0
IL - Horne Owner Ex0n0tion
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 becoatsidered a is:fi tcowtier.
Such "homeowner" shall submit to the Building Official, on a fonii 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 1.53 (Liability or Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, You may he 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, 'L` v of
Northampton Ordinances, State and Local Zoning; Laws and State of Massachusens General Laws Annotated.
Homeowner Signature
C,TteN S DESCRIPTION t F i ilgposrs) l'iaRK goes* ,IIII „ p, ic. .hi
N, F ctn.0 s A:.'^dition t-Ji' i I epraceme:a 4 "iiitdow& A:Ce:i;sti..n(S) t.... ( Roof int 1
Or Boots ., E
Accessory y E idg. Ll Demclitio: New Signs i Decks ` 1 Sidicg a Other `-'
7 '' '1,, !itt `c `r 4 ,i i } ,. tle,C R/(nl�/' ,.._ i Av.) T a4,0. .... .__._.. _. 400,-,—...,, ___.....�__...._
=r+r l G r` �_
/ C 6 x � � r �J / /G�
,,: . .. t ,, ,,,+, 6E.` :it.., ,. ': -k`t Y'...,� .,,I�; t ¢� [� ''4f` ..r`; �
` I .. t., ,: ,.t ` t _14,'r" . ✓ :a ,, , , ^ . .1 ,,. i %i .2t 't _— �.,. \'";". __ '14, 1
62. if New house and or addition to existing housing,, complete the following: {
I'. t';`.t. °t . ta, , i 7..,,`:4`e .a` °€ 7, . t' n 7.,'!'""":',7-"7 - . t.
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"tp -:, -'t it
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tit e 4t,:4¢, t Nt'd F lii,i`d _tl'a:..e ,.0:y . C':, L.,...lii.,Ii:.i.F IHs■"., is 1.0C 'i. '4a, .4.;1 1 .. 34
4r` z P e.l w t 4 : I,, t i rr-r> e` i
.% ` 'xt. 4r 4: =t t, ht :' t, 4.. t i, . .y.., .t' ,....4;ats; t',? (/ Y °'._. N'
SCC T ICN Tai - OWNER ALI i I IGRIZhTiOPN - TO OE .. COMPLETED wuuC14
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 6_0 f G L ( Ue) t&! AA, I
tt 4'; ; . .,.1 Nelson Shifflett, Valley Home Improvement, Inc. . _ .t t
1 .+ �,.. t! , ''t 'r 1`11 , G •
.a! t..F.Jr`td LP.fFEI r I
1
i
Nelson._Shi_f.flet_t.,,,.V: l .ey Hozfte_.wlrtp o .Ement, _Inc,.„.„.. _ t ;t i t:,°A:,t ,,E-1 e;:.i,t
"ie I %i_c ...'fr: . _ . .. 1 '- A(.1t "_ i_. Ft, t"'I c'. . ° Pi l . hits Wiz' .` a, :t4`[ , ,f,„ : 11,,, , ,, ,, , ,, .0,: . . ;t, tot °'t aiC: , . Ii'
4t 4 - ;C — F - -` 4ii..z
t
1 , ;4. CA _ t' I t .._ . _
Nelson Sh-iffleet_
4
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1
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 / h," e / /0e -
Frontage _ /3O / 3 v
Setbacks Front & G o
Side L: ,?v R: /7 L: L R: 1) * 1103
Rear 7 0 • 0 70 • ,
—
Building Height $ A el/ f /
Bldg. Square Footage 5-56 G % 0)G8V
Open Space Footage
(Lot area minus bldg & paved l a c G 9 �/! G / �
parking) 4
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO l/ DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO _V 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 2/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:
^
^ .
r �
Department use only 1
Of Northampton
Status of Permit:
, ', 2 � 1- xding Department Curb Cut/Driveway Permit _ -
212 Main Street Sewer/Septic Availability .,
.ROODl 1()0 Water/Well Availability -
Northarrrptorf, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 F�X 413-587-1272
Other
�
' � - |
APPLICATION TO CONSTRUCT, ALTER, REPA|R, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_ _
SECTION 1 - SITE INFORMATION
This section
]LlPrnper��Address:
` -
j3 *-
� � /2 1-� /~/. Map___ � Lot Unit
' �,� ~_
�/ = ° ' - x"��,��*�.~ . Zone_ Overlay �L
ayDis�c__
'^'
^
Elm St. m�0$do\ CB District __
_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
|
2.1 Qwner of R rd
ti S
Current
4 vL/ Tep~r V -- -- -- `
Signature
_ __-_--___ � ' --' —
22 Authorized Age Nelson Shifflett
Valley Home Improvement, Inc.. _ P.O. Box 60627, Florence, MA 0I062
Name (Print) Current Maing Address:
'_ __ ____ _ 584-7532__
Signature ' �� To/nphvne
'
SECTION 3 3ESTIMATD CONSTRUCTION COSTS
| - -- ---
tan ' Estimated Ccs (Dollars) to be Official Use On y
d i |
l . Bui|din@ �VBui�din�Penn��Fao
/CO VD 4) ' �
,
2. Electrical (b) Estimated Total Cos of
� �
/ 1 Construction from (6)
Building Permit Fee
'"`=~"°' L .,..t. --' ' -- �� / � �� I
6. Total =(l +2+3 +4+ 5> | ��� 80 � — _ ChockNumber �q!�� )� / 3 �� | r,0. ��_
This Section For Offic d Use On _ _ __
/ Building Permit Numbnr __ ___„ _
- __ _ - _ - ____
Signature: __ ___ __ -_
Bu|�inJ Cmmm/minnmf|uqeotv/o[Bui|ding � __ _ Date _ _____ __�
, �
File # BP- 2010 -0950
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 13 BAYBERRY LN
MAP 35 PARCEL 236 001 ZONE SR(100) / /WSP H
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out .� _
Fee Paid ps(oX/ 3 , .� d
Typeof Construction: CONSTRUCT 8 X 16 SHED ADDITION & REPLACE FRONT DOOR
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 1 i
INFO ATION ' ' SENTED: • = - r ' p� r .
Approved , � , dditional permits required (see below) purr Pl g ,� e N p f et. 30 j 1() C) I C
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: § .4 + - ► N S ` i
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
ei /2,9 10
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.
BP-2010-0950
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 35- 236 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 -0950
Project # JS- 2010 - 001409
Est. Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 40946.40 Owner: BEEDE C SHAYNE & GEORGE BOWERS
Zoning: SR(100) //WSP H Applicant: VALLEY HOME IMPROVEMENT INC
AT: 13 BAYBERRY LN
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:5/3/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 8 X 16 SHED ADDITION &
REPLACE FRONT DOOR
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 5/3/2010 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo