23A-137 ¢gttAMP1.
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DEPARTMENT OP BUILDING INSPECTIONS -_I�_
212 Main Street • Municipal Building
Northampton, Mass. 01060 top'"'y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L 52-1''!✓z/5'L l/ /1' t4fzz1 /to f .. % `�l 4 i J. .G_.,
(licenseeipermittee)
with a principal place of business/residence at:
3 / 'i$i.`. E_. 71i : /-'‘:r<77,171m/-/Trz,i7,4 (phone#) V-75—Z1
(street!city!rt to ripe
do hereby certify, under the pains and penalties of perjury, that:
0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
f16!/11:,& . t v, -c-z c , U21 J2� z////' `'
(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 erploy persons to do carrots i'per,construction or repair work on a dwelling of
not more than three units in which the homeowners resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Ad(GL152,s3 I(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 Depertmma of Industrial Aeddeata'Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGI.152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 3100.00 a day against me.51-
Signed/1r' t _day of ' r' 4;,,,, ' 2c)3 For departmental use only
,A � Permit Number
,/1' AI/ !',7 , / ` Map# Lot#
ignature of Li... -- 'erriiittee
'439 SaCJ'9,S-Stf*s „t
Boa'd 3w '9'w,13-09
itvtn9..1.9,(1 ra,,t 1°A0a3.1%
CSFA-060300
NELSON A SHIFFLETT
PO BOX 60627
FLORENCE 1VIA-01062
09/2212014
/ff) //f/ i/ ".-Th
1)/11/ / - tit4J-0"C1.4.5c/4/,.;
Office of Consumer Affairs and Business Regulation
414.. 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration 105543
Type. Private Corporation
Expiration 7/17/201,4 Tr# 226093
VALLEY HOME IMPROVEMENT INC
Nelson Shifflett
P.O. Box 60627
FLORENCE MA 01062
Update Address and return card.Mark reason for change.
Address Renessai Empio!..ntent Lost Card
',CA 1 CJ 4
1 SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shif fet.t_ 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive. Northampton, MA 0 060 9/22//y-
Address Expiration Date
584-7522
Signature (. ....„,---- Telephone
41/9. Registered Home Improvement Contractor: Not Applicable ❑
Valley Home Improvement, Inc. 105543
Company Name _ Registration Number
340 Riverside Drive 7/1711`'
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 El 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-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 ---.
•Cc1:1QN 5- DESCRIPTION OF PROPOSED WORK(check 011 zi2plisolL)
New House J Addition Ej Replacement Windows I Atteiation(s) E: Rooting Li
Of Doors :1 t
i Accessory Bldg. ° ; Demolition° New Signs :- ) Decks ' i Siding [ ) Other j )
'1";:-lof Oct:c*.int. On C! r;';(13.0;r1c t'VO•K` _60-a* c?C CX tj A,..) p.AAlciv4/.../ (4,1 ,A...e.../fry (..52-Al d;A) c/J.kA
,
' iSt utp.. tinn,o.orn Yer; NO )".1.c.1 lip new rlf-rt,t1c.— N'e44. 'lc
LT.,11_;;;;;.: NdrrAivt.' ;1;‘,-,-•;3voil.;,;::,,ii ,11.t..1t ,i ;,;0‘.;.;.-.1r0.2..! ;. '
Pb--_: t",.1:t.a:hcO Pok St`tout,
6a, If New house and or addition to existing housing, complete the following:
,
tkE DI :APIC.Wri , C'E.: 7a,III iy iv,„:) F arrply_ Cot-
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b Nttzninfti r.t' f(;:f•--rF, 1 eacn 711--1:y to-l• ",11,--tnit.' ftott Sttilr'co-r.F
new :',.t.:,01.ki...tat,to
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nt,-1.; t'..it,t;', :.11 Weedt tr.P:'.1",,, Nu— I;
2 F-F4.7%, 1.7;e-serve:tun ',.7;or-pi la-Ltt:: l'evscck ;17.noz•gy C::,.rrc*Lii:(2. ft-or m atitatcl
yr'ot cc:^ftlt.k.:';tol
cixv.:11,..;t...kic.it 'i ti 103 't :-,,t,...E.„!,,,,r1(31,„? 'Yes N3. ii, c:.instruct sm v■ Vit' :00 y; `1C41p1,i,:i Yti,
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t tw,einc;tit ;.",t cell:tir I nor nelnea 'I-tthed i'.1;ice,
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nrm to the Buticnnp, WI d ? !'df".pe P:*"..1.1t IC''f.?
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! k .SLI:t/C -4V1k C .'Y Se'Kr:7r Pr:viy,e%.,e1.1 city *a.ter
SECTION 7a -OWNER AUTHORIZATION •TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
• 'iCt Ye.'L..1. -C.YetSttet. (--- *Ct.-Mrlev wuz.., Nk., . as ,:iv.ittet c; :--.7.: lutieCt V:v:..Eil:i
Nelson Sh• f flett, Valley Home Improvement, Inc.
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rr tt' 1.:*:-..,if i 1 ttotle:tt., tn ..Itio- 1 vt.,,I.,. ..1fttliOnit.o tyi Po, 1.),..to n tip -.teit'-tt ,..-inlA;LItty, t
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if
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_Nelson shifflett, malley Home Improvemamt, Ixic_. , .v., ':.%..,nr,r/Aup-o-l7f.,1 Aefx,t
nEr,by dpc..!urp .:77 : `.;r1t.' Inc''',11terit!.. i.;;riC infOtr",iitX; on. OW forgo irii Kn-itC,ItIWt :11(1 ';'Ut,' ArK; ilecor,tt.t.;, I:.; ',11 ;;),i';:,!. 1,,; pry
1.3-m1r:cgs, z.nc belief.
Siz-,Ei '_:-,C,:- 111": ,:11';';'..: art-J r...2•ta tin u
Nelson Shif f let t
I ;%arr;:r
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
Buildin g 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 C�)
IF YES, date issued: I Icv&''
IF YES: Was the permit recorded at the Registry of Deeds? pie
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 only
ED City of Northampton Status<of' '-1.+ alt,
Building Department Curb Cut/D1-IVeway P rrr
ewer t
212 Main Street S /Septic"Avaiiatx1lty
JUL /3 OUP Room 100 V+ well Availa#iiJi
Northampton, MA 01060 T/of ets of$ ii tural Plans �s
oePT.oFBUiLowswsPA;f� 413-587.1240 Fax 413-587-1272 Plot/Site�Pl
ORTHAMPTON,MA• I•• , ,
ry a
tither Spec! '% k .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION /(414/V I M e r CJ%..x) -S
1.1 Property Address: This section to be completed by office
0707 �-(�� '�, Map Lot Unit
41 Q, 2 Ce_ Zone Overlay District
EIm St.District_. CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: – (e ��/9� �i1 i r4-se
�1� c _y wake a \t- , - nu e.R6,aL .
Name ,,r)nt)` Current Maifin A dry s:
J/ �' /�. _ - Telephone
Signature
2.2 Authorized Agent: Nelson Shif f lett
Valley Home Improvement, Inc, P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
7,7 / 1/ 584-7522 _—
Signature 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
/c, aoa
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) /, Do Check Number 3117/5—I $cJ?
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: —
Building Commissioner/Inspector of Buildings Date
22 MAPLE ST BP-2014-0086
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 137 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2014-0086
Project# JS-2014-000170
Est. Cost: $12000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq.ft.): 10149.48 Owner: LIBERATORE MARC&KATHERINE KELLY
Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 22 MAPLE ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:7/24/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 7/24/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner