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co— DEPARTMENT OP BUILDITNG INSPECTIONS
212 Main Street ° Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Nelson .Shifflett - Valley. Home Improvement Inc .
(Iicen edpermittee)
with a principal place of business/residence at:
340 Riverside Drive, Northampton,MA 01060 (phone/0 584-7522
(sfreet/city!st.drip)
do hereby certify, under the pains and penalties of perjury, that:
(X) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
A.I.M. Mutual Ins. Co. WMZ8005610 01 2008 2/1/09
(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 Comnany/Policy Number) (Expiration Date)
(attach additional sheet tf mocessary to include rofarmation pert in r,g 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 pascal to do maintenance,construction or repair work on a dwelling of
not more than three twits in which the homeowner resides oc on the grounds appurtenant iheecto are not generally co:aidaed to be
employers under the worker's ma esatiet Act(GL152,ss I(5)),application by a homcowteer for a lice=or permit may evidence the
legal status of an employer under the Worker's.Compensation Act
I understand that a copy of this stat.emaat may bo forwarded to the Dq artrrxot of J,,b,�ri al Acadcxo OLioo of Insenanca for the
coverage verification and that friltx=to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
coasuting of a fine of up to S1,300.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.O0 a day against me.
Signed this ?/ day
' of Gam^ C20,d Fcr de{utment l use
only
Permit Number
/a 1� /V
Maw Lot 4-
/la GS04
ISECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
________]
Name of License holder : Nelson Shiff lett-_— 060300
Valley Home Improvement, Inc. License Number
340 Riverside D,ri.ye, Nor thampt_o_n_„ 010.6..0_ 9/22/08
Address Expiration Date
584-7522 _
Signature Telephone
i
9.Regtstered:`Home l mpr`ovemept Contractor. . Not Applicable ❑
Valley Home Imp ov_esuent,_Tn.c.. 105543
Company Name Registration Number
340 Riverside Drive _- —_-___ 7/17_/10
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 kti rNo ❑
11 . Din e;e1 4,xemp.ion
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 Koine 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 --�_.--_---__------_.---.____--
•
5-DESCRIPTION OF PROPOSED WORK(check iftilii IplicsIttrj
1
----VS '
-----
1 Ncw Hotsr.e 0 Addition 0 Reolacement Windows I Altoration(s) 0 Roofing 0
- f 1 of boors LI
1 , .
1 Accessory Bldg. 0 1 Demolition° New Signs [ 1 Decks [ I Siding[ I Other .-.}-----'
Srir„, D C%.,,,,!.1 Li, on ot f'ropoed WO,7k:
4iitcriition :iso a bo7:0111 .,_ V_.n.; NO ACClina now :)e(!rec Ye No
Atiachod Norfativd'' Reno7atinii i;rifirli&lio.A biiseinent Ye S No
Plans 4ttaichcdi-Zoll
64, If New house and o're.Oditien,Ao existiitt'hoLiSidecernpiete the folloW10:
_
a. Use of building : One Family Tv..,o Family Other ....
b, NurriLler el (COTS in each family unit: Number or Bathrcorns,
1'
c. If; till,re,I. garare attached?
U. l'fcf); (3 Squire footage et new construction Dimensions
t,.- Nuinb-er of s.t.cfles?
t. !'l,ethod of heating? Fire (•::.:.:'t:at We cd trivet, Norrib;;,1 Of voch
neri,ry Ccinservaticn Comp:iarc,a. Mi:..scheck E n e r gy Complian,:e form .attached?
Type of co-istruction
i,
( ,,,_ i.i.co.v.i tr Li,,tic a within 100 ft. of wt.:Warta? 'f es No, Is construction within I,00 yr. ilofifiplaul Yei.; No
of baement or cellar It onr bek>w finished vadr; _ _. _. _____
Wilt buildinf3 conform to the Duildin€: and ZoilinE; regulaticni33 Yes No
I. Septic Tank _ Ctty Sewer Pemate, w:-A City water SuOPfy
SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1
ift 0 45L,..ja,lt, a-s Owner GI the subject property 1
„, „ „ _ .,..,„ .„. „ ...., , .„, .,..,, „,..,.0. „,.,. ._ ,„..„„..,..,.....„......,..•
hereby aiigh0r17,e. Nelso4Shi.f,f le t t: Vailey„ Honte_Irapr,oxernent, Inc,. to act on
my benit,II, in 41 matteliThrefative -,,.'7i k lit izec.i by' this bnlding,foeunit ,F1:,splication.
...___
Signazure of Otivner
. lielson—Shittlett i_Valley__Home. Inpx.Q.,xernent.._lac, , :is Owner/Authorized Agent
hereby declare that tho statoinents Lnki inforrintion on the fort:going alpplicration ;,re true. and accurate, (0 the best ol my
kricwIckfRe End belief.
i
i
Si;:ned and the pains ard penz.thids of [;eri'jr,'. P
Ne.l. or1Shi.f..tlett_
t:
Prq.I Mirr..:
Siff:it:31%.:.,
,iiit'
Section 4. 14,/-1 // c ( ) (c, 1 ,"/,ci
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
Building Height I fl
(k)
Bldg. 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 recorded at the Registry of Deeds?
NO DON'T KN W ) 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:
P S 3 3—---
Department use only 1
City of Northampton Status oT Permit
Building Department Curb Cut/Driveway Perm
212 Main Street Sewer/Septic Availability
Room 100 a r Vdtet/Weil Availability , .... .:
Northampton, MA 01060 Two Sets of Structural Plans . , .,4(
phone 413-587.1240 Fax 413-587.1272 Plot/Site Burs".;' w ., 8k t
Other Specify A- i .,r t r A ,� . 3 ry <" Yt t :
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ,2Oc 0 . -r ��s,�`. c -
1.1 Property Address: ,;This section to be completed by office
/L/3 S i'.A S f Map= Lot Unit
'/CniN-15 //<j(\. Zone Overlay District
Elm St.District_ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of ecord:
-Name{Print i� ` �`,, Current fV�li /r,7 `/
;....: �►� % Telephone 7
ISignature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, InQ,, P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
i j 584-7522
Signature / / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building e Liu (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (FIVAC)
5. Fire Protection •
6. Total =(1 + 2 + 3 + 4 + 5) L L i0 3 _ Check Number 2.`-(`4`t9 (1/2 3S,o
This Section For Official Use Only
E Building Permit Number: Date Issued:_ _
Signature: _ __
Building Commissioner/Inspector of Buildings Date ______'
As opct PCOlvtiA C o3_ 6 -0 fog_
•File#BP-2009-0141 R,E rn a p �_ L R. — �� O p f �_L E c._ p ^1#s N /10\1,
A'at,ti( N ` P CrLocA i WAS .t tick R-{.(1A p)
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
e Paid � �t 4 9 9 $S 5 QZ C` 1 G t)
Typeof Construction: Replacement Windows
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO jMATION 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
Demolition Delay
Signature of Building 0 ficial 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-2009-0141
GIS#: COMMONWEALTH OF MASSACHUSETTS
M t, e -� CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2009-0141
Project# JS-2009-000180
Est. Cost: $0.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc
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 0 Box 60627 (413) 584-7522
FLORENCEMA01062 ISSUED ON:8/15/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: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 8/15/2008 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo