23A-105 (9) e, „*.
liTdop r Lam top with tile b.s. i IN �� 1 - �i _ _ ;under cab lights /
I no disposer d.b. 15 t.b. 9 //
s.s.sink/ moen"pure touch” /
Cfaucet with filter...verify
sink is vented _ _ — _ — '
hardwood floor to remain electric work to include new •
panel C
install new mdf bead board 1
wainscot with 3/4" scotia molding recycle 18 �, slide outs 1
CE• under existing chair rail _ granite top
...relocate f.h.w. baseboard as O ' \ `rec.
necessary O is C) ` 1
i
� \ 1, ,
CUSTOM PAINT GRADE gas.downdraft \ \\ ■
CABINETS / DOOR STILE AND range \
OPEN SHELVING DETIAL TO
FOLLOW
Ell remove metal ceiling, install new O
- sheetrock with pre primed 8009
"`) 3 5/8" crown molding \
hanging /verify location \ C
�; \ open shelves here b24 slideouts _ / 4
I Q \ / $ location of open shelving to follow /
add wainscot to match V
- — micro abve
4 _
BOUTELLE KITCHEN REMODEL
145 5.MAIN FLORENCE
0
existing elect. panel needs to be
d.h.. windows o,k. replaced
0 0
00
-11J existing contitions
hardwood floor
tin ceiling
corner hutch
pipe chase...no wainscot /
BOUTELLE EXISTING
CONDITONS
�='.fie-�j1, '�$ �x l �t IIZ �aIlt�t IIlt i =* Y —
��! `%�1(�) �iasaacllnsctts _` .
�o- J 1
"� ---��
DEPARTMENT OP BUILDING INSPECTIONS - _',_1_`-=
212 Main Street • Municipal Building ``
Northampton, Mass. 01060 ow'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Nelson A. Shiffiett / Valley Home Improvement, Inc.
(licensee/permittee)
with a principal place of business/residence at:
20 Riverside Drive, Northampton, MA 07.060 (phone#) (413) 584-7522
(strcetkity/statthip)
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 iob:
American International Companies WC 6554540 00 02/01/2002
(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 employ persons to do mairdaaance,construction or repair work on a dwelling of
not mote than three units in which the homeowner resides or on the grounds appurtenant thereto are not geoeaalty ooasidered to be
employers under the worker's oompauation Act(0L152,ss I(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation Act.
I understand that a copy of this statemmi may be forwarded to the Department of Industrie!Accidents'Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 andla imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
firm of 5100.00 a day against me.
Signed this „today of ? 2— , 2002. Fordeparnnr�sluseonly
� Permit Number
Signature of 7 4 %� 04-". Map!' Lot ii
•ermi r
I SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shifflett 060300
Valley Home Improvement, Inc . License Number
320 Riverside Drive 9/02
Address Expiration Date
Northampton, MA 01060
Signature Telephone
224 / 6P1
584-7522
. :J•a.- :.. ud- €* •psi- €t; < t4t � Not Applicable ❑
Valley Home Improvement, Inc. 105543
Company Name Registration Number
320 Riverside Drive 7/17/02
Address Expiration Date
Northapton, 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 Eianotion
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
1
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: / e f ADC j
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes .._t/ No
Plans Attached Roll . - Sheet
6a. If New house:and or addition to4xjsttniaQlishigismapletethe following:
a. Use of building : One Family _ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms___
c. Is there a garage attached?
d. Proposed Square footage of new cot(sfr ct�fon. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each ___
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement 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.
Ann,_& William. :outelle , as Owner of the subject property
here. authorize Nelson Shifflett, Valley Home Improvement, Inc . to act on
my .half, in s relative 1. work authorized by this building permit application.
ir,
Signa ure of Owner Date
1,_Nelson Shifflett, Valley Home Improvement, Inc. , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name
/r
Signature of Owner/A: nt Date
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 tilled in by
Building Department
Lot Size
Frontage l;i
Setbacks Front ,
f6/1 t0' 3
Side I.: R: I,: R: 6 L
iv
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 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 l 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: _ ._
s
City of Northampton 7 � ,, ��� e
Building Department , = x
x
212 Main Street / a � w i t ` '
'
_. _- an 100 , f
b) 1;, r�=a on, MA 01060
ratio • : 1240 Fax 413-587.1272 ti'r,; b ���i
APPLICATION TO CONSTR . 9✓, 4TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Pro ert dress:
This section to be completed by office
1��SoW Main Street Map / ✓ Lot ` � •Unit
Zone Overlay District
Florence, MA 01062
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT -`
1 1f3
2.1 Owner of Record: ,...14-5"'S. Main Street
Ann & William Boutelle Florence, MA 01062
Nas (Fran Current Mai{i g Addre
.a/ ,i , '`' . X16 ' f
�, 0,1„ Telephone
•ign.ture
2.2 Authorized Agent: Nelson Shi f f l e t t
Valley Home Improvement, Inc, P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
2titfyieet47 584-7522
_______
Signature Telephone l
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item 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
..02 Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 1
5. Fire Protection �//1
6. Total =(1 +2 + 3 +4 + 5) /?, t•1 Check Number J174Cj� r�5
,C
This Section For Official Use Only `/
Building Permit Number: tjt//c? 6 ' '1 Date Issued: —
I Signature: _
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0669
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P 0 Box 60627 (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 "_TS i5
Fee Paid �jj J
Typeof Construction: REMODEL KITCHEN
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
INFOVINIATION 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
1114/ /-0V1-6
Signature of B ding Of ci 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.
3 5°rititNMAm ST BP-2002-0669
GIS#: COMMONWEALTH OF MASSACHUSETTS
MapBlock:23A- 105; _ CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0669
Project# JS-2002-1068
Est. Cost: $12000.00
Fee: $50.00 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:1/24/02 0:00:00
TO PERFORM THE FOLLOWING WORK:R E M O D E L KITCHEN
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/24/02 0:00:00 14555 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo