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W s. "' DEPARTMENT OP BUILDING INSPECTIONS , _
212 Main Street 'Municipal Building ' o,,41 = 5�,,>'
. Northampton, Mass. 01060 ttm
WORKER'S COMPENSATION INSTJRANCE AFFIDAVIT
I /l/E EH / GP" - Z_Z_77 — / l/ f_ /fl - i; -L
(lipermittee)
with a principal place of business/residence at:
3 '10 , ) / 5 f.b 2.. z) ✓`Z/t/0 �177r7,2 ; fs'Id (phone #) '' 8 ( ZZ..
(st t/city/ state/2ip) 4/ O
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 "
(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 workers 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 coatrastors)
( ) 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 persona to do m-'- construction or repair work on a dwelling of
not mere than three units is which the hottteowaer resides or as the grounds appurtenant thereto are not generally wondered to be
employers ender the worker's oempeasation Act (GL152,,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal starts of an employer under the Waiter's Compensation A.
I understand that a copy of this ntatemmt may be forwarded to the Department of Industrial A c dent& OfSoe 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 $1,500.04 and/or imprison of up to on year and civil penalties in the form of a Stop Work Order and a
fine et a day against me.
Signed this - / 51 day of / 20/2.. Fcr departmental use only
Permit Number •
A U .l.,.' < A"- Map# Lot #
Signature of L'- • ermittee
I SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shif f lstx _ 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA t11 060 9 / 22 // + __..,__..
Address Expiration Date }}
584 -7522
Signature Telephone
9. Registered Home' provement Contractor; Not Applicab le ❑
Valle Home s • �, • 105543
Company Name Registration Number
340 Riverside Drive _ 7/17/14
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 No ❑
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 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 -vear 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 tune 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
. 5. DESCRIPTION OF PROPOSED WORK (check All SIP_PtiC*t*)
New Neese Addition U Replacement Windows Alteration(s) 0 Rooting 11
Dr Doors :1
Accessory Bldg. J Demolition° New Signs " 1 Decks Siding ( 1 Other
on Refhe4L 7 1.eeke t // (4) Se, er J 4At a rre.J.141/9
e°,1.np 5t1r Ar.ft ..,7
teL: Yz-P,
-
Pok evt
lf New house and or addition to existing housing, complete the following:
(F.t- C'e 7 am v ' alThel
r's..mrier e.1 , 0" t T ill 'C.:C.17F,
1.,
`Ic.nrd J `,V(Atovr t\n-
C( C.orl; cc. :ne•gi L'n:c f'.111 :tact cc; _
vrst t Cf:/ f,t1
w,(11.1 10) ;.#1 ^..et "C.; c;:plistr.Ict :00 yi
:3■1*-t9"lr (4,1r 1 ;I:br gf.
'lc a f'v °' t. Hur `) too .1Itik— c° 111
St3:11c C:y SeAsH Pt Cty *Met Soop
SECTION 7a - OWNER AUTHORIZATION - TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as c e =,uLiect p'.x.:ctty
Nelson Shifflett., Valley Home Improvement, _Inc.
rr' • r to
1 7 . 40 r
—
,Atr 3 . ? 3
• tilett., . , 17e1
dor 7r? rc *.*-,:).*. 1,'. Etna tht.1 ur e, 1°,) "itt iv' try
t.rcwk nc°
Li: s
Nelson Shiff1et
r 1
0°'
ALI 44L/ 3 5-
Section 4. 1904-1r
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 T
Frontage
Setbacks Front
Side L: R: 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 1/ 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:
RECEIVED
MAR 6 2013 Department use only
City of Northampton Status of Permit
r
oEP �,ui_or" °'Pr- T' °N Building Department Curb Cut /Driveway l? rmit
NORTHAMPTON, MA 01060
212 Main Street Sewer/Septic `Availa ity
Room 100 Wet /Weil Availability ��
Northampton, MA 01060 Trets of Srr viral Plans
phone 413 - 587.1240 Fax 413-587-1272 Plot /Site P(
Other Spec ify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
/l ��G krij 1 ' (1 ' h
SECTION 1- SITE INFORMATION „1 , g% // r✓ c W J`f i(rf e'X )`,s2 C vP'1 , i1 ,4
1.1 Property Address: This section to be completed by office
,F/ Map Lot Unit
/ f 1 2/ (� �� Zone Overlay District
Elm St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 1 Jlsdr /;
/- 0<%f/ 5 / L---/0 L f 5- /71,1 - Name (Pri. Current Mailing Address:
Ii 1 41161/ _ Telephone —i ,-7
Signature
2.2 Authorized Agent: Nelson Shi f f lett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name (Print Current Mailing Address:
./ 1/6 .',� 584 - 7522
Signatur- 1/ Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item 1 Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) dd co() Check Number od d 9$ MO
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: _
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0871
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 503 AUDUBON RD
MAP 05 PARCEL 062 001 ZONE RR(100)/WSP(71)/WP(9)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3 b o � I o)
Fee Paid J
Typeof Construction: REPLACE DECKING & RAILS & REPLACEMENT SLIDER
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION 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
134
.0>, ;26/—/,
Signature of Building Of 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.
503 AUDUBON RD BP- 2013 -0871
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 062 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 -0871
Project # JS- 2013- 001492
Est. Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): Owner: PACILIO MARTHA N
Zoning: RR(100)/WSP(71)/WP(9)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 503 AUDUBON RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/27/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE DECKING & RAILS & REPLACEMENT
SLIDER
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 3/27/2013 0:00:00 $120.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner