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K 'r: DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATIONiSURA.1NCE AFFIDAVIT
I, Nelson Shifflett, Valley Home Improvement, Inc .
(liccnsecipermitte-e•)
with n a principal place of businesslresidence at:
340 Riverside Dr. , Northampton, MA, 01060 (phone..=1 584-7522
do hereby certify, under the pains and penalties of penury, t_ .t.
(x) I am an employer providing the following worker's compensation coverage for my
employees wor1tdng on this job:
Acadia Insurance Co . 0109302-11 2/1/06
(Insurance Company) (Policy Nu=her) ( iraricn Dace)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and havered
the contactors listed below who have the rolllowing worker's comnensation policies:
(Name of Contractor) (Insu_*anco Compa..y/Policy'vrrnbc ) C xpirario:Date)
(Name of Contactor) (insl a c: Company Pclicy Nttrrber) :-pi anon Date:
(Name of Coru-accor) (Insurance Company/Policy :tiuuber) ;E.xpiutio•n Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Loath adho:ocn1 thcct if necessary to intrude nfornsstioa p rt imrg to all pawls)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plenac be aware that while hcmeow sera who ell ay percm to do era r^r^a nrp.a cfftm ion or r pa r work on a dwelling of
cot mote than three units in winch the homeowner resides of on the grounds a t th rcto arc not generally considered to be
e loyers under the worker's compensation Act(GL152=1(5)),apptinrion by a homeowner for a license or permit may cv done the
1e�I atwu of an employer undar the Wor$e'a Caution Act
I=4c-stand that a copy of this eratemem may be forwarded to the Department of Inehsrial A.oad a otrioe of lrrwaoce for the
coverage vet if calico and that failure to secure coverage under section 2.5A of MGL 152 can Ices'to the imposition of criminal per,ir es
oocrithr 3 of a fine of up to S 1,500.00 and/at •-.--isocmn=t of up to one year and civil penalties in +toe form of a Stop Work order and a
f:=of 5100.00 a day against tne_ �7
Signed this
• /y day of /7/-4 c d For departnneceal tueonly
/4 / //,� Permit Number
+
Mar*1 Lot#
/V L50/, S/f/ Zi/
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shifflettt __ 060300 _
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northamnton� MA 01p60 9/22/06
Address Expiration Date
'� 584-7522
Signatur k �� Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Valley Home Improvement, Lilo_ 105543
Company Name Registration Number
340 Riverside Drive 7/17/06
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 cenial of the issuance of the building permit.
Signed Affidavit Attached Yes X 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 he
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
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition CE1‘' Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ Other [Lr--
1 i
Brief Description of Proposed Work: Pen900i SAc? ) r f✓v,J Lfj �/c4 f>00 ! r S +tt Ci'( A
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative _ Renovating unfinished basement Yes No _
Plans Attached Roll _ - Sheet gj- Add /k,'; h \Sib". o } I _ .�iIif// 64 sr 3JbJL
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family /..------- Two Family Other
P. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? ,j C; '/,a ��` ^ ;J' c c
d. Proposed S care rootage of new construction. �` Dimens:cns / ( pa,4 + Le)�
Number of stories? °'�(�4t/�
lethcd of heating? - Fireplaces or'WVcodstcves Nu:mcer of each
g. Energy Conservation Compliance. /(//i %lascneck Energy Compliance form attached?
I
Type cf construction
1. Is construction 'Nithin BOO it of wetlands? Yes Is construction within 1C0 yr. "ccdp,alr Yes `c
Depth of basemen: or cellar floor below finished grade • .
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /9w,, , 6,,,/z. I/G , as C•wwner of the subject property
i
hereby auth-rize Nelson Shifflett, Valley Home Improvement, Inc . tc act on
my behalf !1 all matt , r 've to work thorized by this building permit application.
Signatur of wner Date (0 e� C)
i. Nelson Shifflett Valle : •,4 - .t• • - UU - . • , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best cf my
knowledge and belief.
Signed under the pains and penalties of perjury.
Nelson Shifflett Pleal/ill
Print Name
r �
Section 4.
ALL INFORMATION MUST B r COMPLETED, or PER1MIT CAN BE
DENTED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 7)S 7) 5- 3
Frontage /10 // 0
Setbacks Front 38' 3.
Side L: 0 R: & L: O R: S
Rear 20
Building Height /jOJS 1. A- v0 (//0"e C Y
3s
Bldg. Square Footage is-6,v ° l6,,
Open Space Footage
(Lot area minus bldg&paved /^ 2
parkins) �� �fJ�t� �)T
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findi ; ever been issued for/on the site?
NO ' DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Re stry of Deeds?
NO L- DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of w :er or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to e obtained from the Conservation Commission?
Needs to be obtained Ob ained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and locati n:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
. Pmn V ely
City of Northampton Status o1 errrirt:--
Building Department Curb Cut7Drrveway Permit �f -
212 Main Street Sewer tic AvVaU i l G 5 'J
`J
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of atPtEns
phone 413-587.1240 Fax 413-587.1272 Plot/Site Plans
Other Specify-- "�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
I � \ �� Map Lot Unit
f jo}4.tvte eio6 Zone Overlay District
Elm St. District CB District
i SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Narn (print; Current Ma ling;'-.cdress:
c -/v J
��.. Te!ecnone
Sir �
ture
0.2 Authorized Agent: Nelson Shifflett
Val ey Home Improvement, Inc . P .O. Box 60627, Florence, MA 01062
Name
lame iirmt) �+ ��, afrent Mailing
584-7522
S grature Teiconone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be j Official Use Only
completed by permit aoelicant
5u1iding (a) Building Permit Fee
de,00 t S6 0/ 010
2. Eect r cal (b) Estimated Total Cost of
� 22 OUd
/COO Construction from(6)
3. Plumbing /00 4) Building Permit Fee
110 •Od
A. Mechanical (HVAC) ,vbe"
5. ire Protection
6. Total = (1 + 2 + 3 + 4 + 5) r ,f) OV J Check Number 20 le
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0446
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 143 SOUTH MAIN ST
MAP 23A PARCEL 105 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out r
Fee Paid jO176- #//o ..
Typeof Construction: REMOVE 5 X 20 FRONT PORCH&REBUILD 8 X 20 PORCH
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
INF9RMATION PRESENTED:
L' 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 Commis '
xn
2. ,5---
../...... "4""..6/,11..-'441----- _____jet/2h
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.
143 SOUTH MAIN ST BP-2006-0446
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A- 105 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0446
Project# JS-2006-0662
Est. Cost: $22000.00
Fee: $110.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq ft.): 7710.12 Owner: BOUTELLE ANN E
Zoning:URB Applicant: Valley Home Improvement, Inc
AT: 143 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11/2/2005 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE 5 X 20 FRONT PORCH & REBUILD 8
X 20 PORCH
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 11/2/2005 0:00:00 $110.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo