30B-097 (2) The Commonwealth of Massachusetts
° -°"` Department of Industrial Accidents
-- s—,:_, Office of Investigations
:' 600 Washington Street
s = ;,;r Boston,MA 02111
"e. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /N , Please Print Legibly
Name(Business/Organization/Individual): �/G-�-e-1 �f - " 1 �t/////tY// / 7
Address: 6`uo /C l vZzi�5 l / cc /2/
City/State/Zip: /4 7"/ ft 1424- GlO&0 Phone#: 4%,- V- 75-2 2—
Are you an employer?Check the appropriate box: Type of project(required):
1.(N I am a employer with J$ 4• ❑ I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp.insurance comp.insurance.t
required.]
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12: Roof repairs )
insurance required.]t c. 152, §1(4),and we have no 13. Other 1�.5 U/ai
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _
'/ �
Insurance Company Name: //% / _/-17L- � t G //
,G �t - i � '
Policy#or Self-ins.Lic.#: f - ' Expiration Date: 2/, / / 7-
Job Site Address: /3/ Fe a, ems! City/State/Zip: f'�01-2of.P, D 10(9D-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c•fist f Per t- rains and enrilties f„=pe ry that the information provided above is true and correct.
U ,,! Date: e lof
i/5
Signature: I,� i/l •
Phone#: 4//3- `Z`7;7 7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I SECTION 8- CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shifflett 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA J060 9/22/0.
Address Expiration Date
584-7522
Signature Telephone
WCYr
istered''Rothe"tmbrovement Contractor:: Not Applicable ❑
Valley Home Impr�yPmP„rT om, 105543
Company Name Registration Number
340 Riverside Drive 7/17/1*
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 0
1 . r 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
7:C11CM S. DESCRIPTION OF PROPOSED WORK (check &I
New House Addition 0 Replacement Windows Alteretion(L) Rooting
Or Doors
Accessory Bldg. Demolition° New Signs 7 1 Decks ; J Siding Other,
• Ethcf eci n c Prclx,(Atc ksvo, ,ht ft-411012-e Flat*, oznsetiparkr attic • o.e r' yr-
ckcIrk LUeot-4-tvx-siart Ps,11150.0de. S s ul) Or1P-aceci. rzo F6- J
,Ltr,eri“.1-on o' existinp bftcrc.Om NO Acdn'te, nett,'nertrnorrL X .No
Attache::: Narrativt: Renov.,:tin.g tJ,v,erner t Y NO
Plars fqtached
68. If New house and or addition to existing housing. complete the following:
7armly Two .7amilv
N4mber c rcOnr'S Ln eac.n tarti:y untt: Niumeir Cot BatrirCorme„ _
t`... h.; tiara a garage attached?
rtrziottee. Sur e lcote of I-I e.tA' ,':;•onstroct. 31) Dt.Ttertsto.v,
;4t.trrttr-.rr C-Jr
Vezhoi r..;`• hootrig? r Or WCodtLteve,;„ Nu -b er r.)f coch
Cc-servaticn Compkrt:e. klascfteck EnorgyC:trmhw:e form attached?
he of CC ,1iutiC1
cciAr tic- mthin IOD t of wp„uano's? les construction w:thin 100 yr, trootiplarn MO
Derith uf otir,ernert1 (eh. ( Luor below iialheo glade
Mil WI h Idir onform to the BuiIOiriE and 2orirtra rdaticnO Yei;
No
L Septic Tank Cy Sewer t>r At;.ite we 'City water SuDpiy
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
MOS-k—A3f0 be-e3
, • as Owner et :re subject prDpity
herjrry autnrtrt7e. Nelson Shifflett, ya.11ey ,Homemproyeraent,_Inc,... fx-t
1;! w)lk authcri;red by trot b.;th':Iirtg. pforni: a ciplIcAtio-i
1.111111111111111111111111111111111111111111111.1111111111—
_Ilatae___Improveraent, Inc. , c ownK/Allino!-Irefi Age.trtt
hereby ded arc that : statornehts and inforrntion on the forKoirrkz aoplic4tion a.re t.71.1t: ,ord ieout u the 1, 4 of try
Lrewlocrzo rric
•
'Zizr-LcJ tf-C 23.7-J uttca
Nelson Shifflett_ --
r':i!!` !
ed 8/0? /13
0:
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
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
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 k
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. re t ere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
—I
'� _1 1 \1(2— � Department use only
-- `! City of Northampton Status of Permit
I 21 2013 lU Building Department Curb Cut/Dnveway Permit
QUG 212 Main Street Sewer/SepticAvailability
&Gas Inspections
Room 100 Water/Well Availabilityt ..v
Electric,Plumbing MA 01060 ,.,rthampton, MA 01060 Two Seis of Structural Plans
Northampton, �
Phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans .w,. ,;-
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
—
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
139 Fe i y L S-t-re ± Map Lot Unit
F lOre.tl.Cet M,A- OtcX'°L- Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(Y)P iZ-K-- «(Z:y,tit -�12<- /37 federal (Sired F lorence, MA o to&a
Name(Prin. 1 Current Mailing Address:
trc- ►� Telephone
gnature
2.2 Authorized Agent: \)al,le� (-4ome-
N e I�son 5h,�-CV ie 7-1 -\p rOemkf1 ?LI-D R oex-s i ck Dr-. Fiore-nee, ,P-0/06,D_
Name(Print) Current Mailing Address:
/ 4/3 — 5-9-t`-- 75a
Signature
7/ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building di J3oo, o0 (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) 1 1500, DC Check Number �J -93
This Section For Official Use Only
Building Permit Number: Date'
Issued'
Signature:
Building.Commissioner/Inspector of Buildings Date
File#BP-2014-0235
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 139 FEDERAL ST
MAP 30B PARCEL 097 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3 J5"93
Fee Paid
Typeof Construction: INSTALL INSULATION&WEATHERIZATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
- olitio, I elay
�� 7—,1713
Sig . e of Buil ing 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.
139 FEDERAL ST BP-2014-0235
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-097 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0235
Project# JS-2014-000389
Est. Cost: $1300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 9888.12 Owner: BRUMBERG MARK D&DONNA B LILBORN
Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 139 FEDERAL ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:8/29/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL INSULATION & WEATHERIZATION
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 8/29/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner