31A-176 (2) fiN
��.�� ct ° .� Wit
.. :,. '" �' ( B lassacllnsetts _ _
��, -oo
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building 7 `� •. = s " s�'
Northampton, Mass. 01060
WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT
I, ,(/E L5 oAf s/1 / /&7T l/ y /iL"e_ -7 /e-a/2 //Le/1 i, _2-71 L
(licensee/permittee)
with a principal place of business/residence at:
3 `¢o / of 5 1 a lVt.li/`z / �/D�7f, r�i�/r; 0'I9 (phone #) 58 el' 7
(street/city!sttatehip) e// 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:
Acadia Insurance Company WCA5029908 2/1/2013"
(lnsurance 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 ifx 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 whilo homeowners who employ persons to do maintent n, construction or repair work on a dwelling of
not more than time units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act (GL152,,1(5)), application by a. homeowner for a license or pemitmay evidence the
legal status of an employer under the Worker's Compensation Ad..
I understand that a copy of this statement may be forwarded to the Department of Iadusirie1 Aceicknef Office of Insurance for the
coverage verification and that failure to se ure coverage wader section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to SI,500.00 and/or imprisonment 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 me. T
Signed this . / 57 day of / � 2 For departmental urn only
Permit Number
1 / ' /../ Aasf ` A"- Map# Lot #
Signature of L`r • • ermittee
CSF A-060300 z
E1,0* A S1111.411
Pf). BOX 601,2
1' LOREN( E k 11106Z '
09/22/2014
/
o f )//7 "( (1/ /1/ / ) (7 , 7
A:1,111,5 aid
10 Park 1 7)
mpr vi nt Corttractt)r Ri rim
71 7 ; 4 Trl
VALLEY HOME.1%1`PRSVEMENT
N&sen Sheett
P 0 Box 63327
FLORENCE MA 01C4:32
t ptiali tQt (.4 \IAA rs—t‘p lip: eh 01,4e
If tlik. rti 0,t
1 SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shifflef 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA 0060 /1`t
Expiration
9 22
Address p Date
584 -7522
Signature Telephone r t
9. Registered Home Improvement Contractor: Not Applicable ❑
Valle H,' - fl• • - ., - + • . 105543
Company Name Registration Number
340 Riversid Drive 7/17/1'/
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 X No ❑
1L - Home O wner Exempt
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 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 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 �. — �...
, E
'ACTION S. DESCRIPTION OF PROPOSED WORK (check all applicable)
i New House 1 Addition U Replacement ...... n_...
r L t Windows !Alteration(s) 0 Rooting 0
Or Doors
Accessory Bldg. 0 Demolition0 New Signs f
g ) Decks ] Siding [ ] Other
/� � If' L�r_w rat =on + f'rc1t >�eG' 04G'� <. /r�)p/ l-� c J(fr - (4G � G /sir 0 neale / .
:,l,er ttrC>n 0 e�'Istinp t)rr:ri ono _MS _ NO Ac!1 ng new ne roo-r " �f
f YES Jr,
Attache "slarr jti' Renj+dtr€ p iifinisited i tsctri rit Yc No
Pb-' s ttt.ttavhed Roll S=`)eet
6a. If New house and or addition to existing housing, complete the following:
ii 1.1 ;e of Pudding : One 7arti ly Two amity Other E
r
i
b i \i.tr o r tom' icon's in each at'my unit: ^+lta'�'t^ -- of 'Bath ccJ."n
p i
i
c„ lu t -ii re garage tz the ? _.____._ M..
i
J Pre. ;; i', ec: St u.. rt luot;iRe f,f ntv, Ortglt.10::.rn ______ )r•tter'r=,r =. `t
/ 1) I. "�'e od of !tcr°+tir1G? Ci or 'Woce,A,tcw f':urw.b =r of
cr+eh
g F.r.ergy Cc:7servaticn Corp is -ed. af_ M- scheek Energy Cornplionce form 8 tact.co? _____ . _ _._
'Type ;,t cr: ^1,1ructec
ti. G'c. +:ti,„ctrtii wrtlicl 100 't (it we't silos? YES No. 15 construction w,:hw !Op yr. '1;;,- „;;lpl,arir Yes P.,,
i , t °r "r of orement or c;t°iiir t; )or below "int hecf grade _ _._ t
,. W €It bu:tciir'p, ucrform to :he 1311aicling aid 2oriirrg r.egg.datic``. ic? Yes No
i. Septic enk C!,'? Se %v r pr'vate cd'e l ____ City water Sup y ..._.._ _
I '
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
7�G►'c'm 4 gK 0,a� .. .,_ , as Owner ct Ere subject property
n I;y ;alt( nrrar Nelson.,. suit f le Valley._. Home Improvement, _Inc. try a _t on
my Ur: `sil r(t 01 r"lr'iiterb re ,3 tt.c lu wCiK authorize Oy thi, 1,,, d.ng, peer? ?.it s' S,`lplicatio'r.
Sigra:dr: of 0+x,"1er "...:ate
.Belson Shi, flettt., Valley Home_ Improyement,_,Inc, +_ J.a•ne:r(Atlt e riert Aeertt {
hereby dectiirc that t?lt*. strltc:rmc *r ",t. tied itfotr•iation On the, foregoir°fa applicdtiorr ;re t'uc drrd rsuCur tt., to We t >fr,e, GI ivy
1~:rcwlcccge E nd belief.
Nelson: Shifflett_.___
' Jr or , rra A
St 'r pr tc:
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: n L: R:
Rear
Building Height
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 permit re • lieu -t 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:
r •`
rr n Department use only —
- --, C i t y of Northampton
I S #atus ofi P r�iits . '
F uilding Department
Curb Cut /Driveway Permit
FE6 4
OI3 212 Main Street SewerfSep ��
L i Room 100 ' `, five -
4 / W e ll Avat)abitlty f
°E Northampton MA 01060 TW Sets of ' 0, #ur Pla �x ¢ 'y
— - p rf *e -413-587•1240 Fax 413-587-1272 PloSite R � z - T
z
�i j t / _
t
Afi
Oth §r '� , , ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION kei Zv/ A
1.1 Property Address:
This section to be completed by office
?l /69yNi i JJ I1 Map Lot Unit
/Pi i0i/Yn)N 4 4 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
:Es cE ( D y: „f 4)i."-
- Name rint) Current Mailing Address:
So, 7S- /- el, / Co45 / �.
\77184-4€, n
Telephone.
Signature
2.2 Authorized Agent: Nelson. Shif f lett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, M4 01062
Name (Print) Current Mailing Address:
A 584 -7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7-57) J (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
o� 3 Construction from (6)
3. Plumbing ,- Building Permit Fee
SOO?
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /317) 0 Check Number 3 1) :% P o
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: ..... _._
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0744
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 26 MAYNARD RD
MAP 31A PARCEL 176 001 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 w / /a ��
Fee Paid `�
Typeof Construction: REMODEL BATH
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
INFORMATION PRESENTED:
V 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
emolitio • Delay
7 -/S
Sire of : ild g •ffrcial 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.
26 MAYNARD RD BP- 2013 -0744
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 176 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 -0744
Project # JS- 2013- 001255
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 14984.64 Owner: RUDDY DANIEL & BEATRICE C
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 26 MAYNARD RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:2/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH
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 2/7/2013 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner