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35-186 °•, The Commonwealth of Massachusetts ." `° �' Department of Industrial Accidents N i Office of Investigations �, Z1 600 Washington Street ice.,=.4; Boston,MA 02111 3,a ..s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Llectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 441.L-Z-% / 9.7/ff2(,1.(f/it ill! , _R-7 L-- Address: ];7-() jC i;,r i`',5 f / /Z-/ "-L_ City/State/Zip: ",!,,�i/r1///7)/1.i'i f/- G'/O c.'G Phone#: 4'T-. 1 V- 75-2 2-- Are you an employer?Check the appropriate box: Type of project(required): 1.C,E1 I am a employer with / 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13. Other 1 e ICht iOYY) 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: i�tf)/ 7 6/,e. / Policy#or Self-ins.Lic.#: l�� /� ? C% >' Expiration Date: -:-2,/// , 17r / Job Site Address: 139'1 "R jan Ck- City/State/Zip: r I or ce l MA- c 1 C7(0'D 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 iu the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. i'se advised that a copy of this statement may be lot-wailed to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c.rd ' ,ruder t .v pains and enaltiestit.7.4--c'ipii4i. nevi ry that the information provided(above is true and correct Signature: �i�iil Date: _ / /i3 Phone#: /Y'...3`—%,J ,% - Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Isnaring Authority(circle ome): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 n1060 9/22/f - Address Expiration Date 584-7522 Signature Telephone v er . Register Home lira3proviivtent Contractor Not Applicable ❑ Valley F�ome I r ya lra?�# , In 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 Z No ❑ 11.. .Home a►8Viit Exe>Iiptxoi 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 • • ,C1'.ge.N 5. DESCRtPTION OF PROPOSED WORK(chetr..k Now Hout,e :::: i Addition Li Replacement Windows i Aiteration(s) E."-: Roofing 0 I a! Doors Accesem Bldg. C.7., Dem::.litior7-7 :3-ier..,' De, ..-1:..r.lon ct Prcpc,•:..ec ':/0k 71-nsvivaiv. all te_ 4 6"rd 1 t)ID rilisulak box,57/Is e4,,Veg r. ri ::,-,' (toi5nt.7 hilr:Mnrri YF-..r. ...)<„ "\lc Ar...1‘ng new nerl -)C-r`. `res AtteellOU Narriltrut` .;-110'it-ltrii, '.;lifinliAtt'.1 taa=A-.1111,7,.t • Plar's Attached Rh I Ga. ili New house and or addition to existing housing. complete the following: ( : a uLE cd. Dutichii: • Cfle. .7am ly Two Farmly 1'; 1k2m0er cl !cells in each family unit Nurrib-z-r or Bathrcorne_ ______ l l c. Is tnere a g.arrage a:tached? i i ci r!f•.;Po'AIG Scurg F...lk-.414: cc new,::;ow.:tructJon Diliensic.qs f. Ylothoi of heating? rrt.,p.,,OeS or WCCdStOv,:VS Numbt! Of each r E Frera-v Conservation Comp:jar:::,.e. tt/.:_zscheck Encrgy Compliance form attached?------- ly .ot cc-...structicri t. ' ..,..:(Vitlif iXtiCh Within 1W ft of weuancs? Yes No. Is construction wraur 100 y!. rlooftplasn ye,. , NO i, Dt,•,,rth of basement or cellar libbr below Nnished grade k. Will building conform to the Building arid Zoning retrulations? Yes No i I. Septic Tank City Sewer Private well City water SupWy , SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT " - % Lciwiri ,4 ,iv5 ke) as Owner cf tm.e subject property hereby airtnnri7e Nelson Shif.flett,_yalley Home_Inproyement,._Inc to,:.,. t on my br.r..'olf, in al rtes reiati.-e to g„v- i',,T authe.fized by this l.XitiCialk ptirmit..Foplicatira). SiRna:ure or Owner Es.atc _ - • • -' # - - 1 - _}1.02:11eIMP.rnXeMenti_InC.., , AS Ovener/Authon2E-r1 Agent hereby de.clarc t'nat -.h.e. statements and inforrntion on the fortgoicii:inviication are true and accurate, to We best cl my krewleogo end belief. Signed Jnc c! th: dsins ard pcnuitit"s of L:er ).. Nelson_Shif f Lett Przr1 Nam:: /, Itir/Ad 4 AlAilAl ci (42//i3 ________.„.... ., . ..,.Jr . .., or _ rkr±1,9, sres.,... r..,or ,...'e• ■ ,...k.---.,,n, . _:.t., — 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 i </-**/ 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 DON'T KNOW X 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 .l'c 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: \-- °\r Departmenf use only ` i ty of Northampton Status of Permit �(;r—�� \\ nDePartrnent Curb GuUDrlveway Permit V SEP ` 0 203 12 Main Street ewerlSepticAvailabillty Room 100 WateNWell yallalilllty= ampton, MA 01060 Two Sets of Structural Plans �t> plumbing 8 a�IFl�0 , f Electric, - 7-1240 Fax 413-587-1272 Plot/Slte Plans Northampton a o- Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property This section to be completed by office 13q rrtyAddress:! l Qin BC • Map Lot Unit nl or-ex-ice i.&Pt 010(oa- Zone . Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e ct ct.)t n Mci- -u 51 ;0 ( 3°( 2 ct -o1- rl vrer��e I( - Name(Print) Current Mailing Addres - 11 ? ,v Telephone Signature 2.2 Authorized Agent: ` GLACet, 1-1cme_ �mpr7s\rewu� 3,1/0 Roze-stogy Dom. �cor�+IcPAA- N- Name(Pri.t) _ s , Current Mailing Address: m ,' y q( 3—Sey ._ '75 .� Sign. - - ' Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee ©?5'00 r 00 2. Electrical (b)Estimated.Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection e 6. Total=(1 +2+3+4+5) .5-Z < (�0 Check Number 3/S'3 iSo`� This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0300 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584-7522 PROPERTY LOCATION 1397 RYAN RD MAP 35 PARCEL 186 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / J Fee Paid 105 Typeof Construction: INSTALL ATTIC INSULATION&WEATHERIZATION 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 I- I!,ition Delay (--------7> ,V,01-/_ 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. 1397 RYAN RD BP-2014-0300 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 186 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-2014-0300 Project# JS-2014-000498 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 1111215.60 Owner: MATUSKO EDWIN G&EDWIN G JR&DAVID L&DANIEL C&D KUZMESKI Zoning: Applicant: VALLEY HOME IMPROVEMENT INC AT: 1397 RYAN RD Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:9/12/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 9/12/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner