24A-177 (2) �..(iiAMp emzgi 04.
$ C�izf r of Norillantpfrin p =**.
$;�'1� �; �fjl6 Alassachnsetts �` -
DEPARTMENT OF BUILDING INSPECTIONS = r`
• 212 Main Street ' Municipal Building -`Sv
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L s�1-G/eA, 51LirycM. r/� F /(a i %�-1/V /S`n2-4r,.�rn(___.
(lipermittee)
with a principal place of business/residence at:
� 53 f /61v /�-s 1. • . /Z1 ,,/1--)Gi 7,1917/7/ZYZ r/1 (phon #) e(/-JvZ2
(street/city/s t i7
do hereby certify, under the pains and penalties of perjury, that:
0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(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 homeowoxrs who employ persona to do ims1t,r!„ae.,.,c vetion or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act(GL152,ss 1(5)),application by a homeowner fora license or permit may evidence the
legal status of an employer under the Worker's Compamation Ad
I understand that a copy of thin uatemeat may be forwarded to the Department of Industrial Accidents'Ofoe of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to$1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fins of S100.00 a day against me.
i it-
SignedVii.' _day of -e J i, !k 1^t 2t1 3 For departmental use only
,� � Permit Number _
/Y L .NII1� /.` i Map ,Lot it
tgnatlre of Li.. "ermittee
•■■
M35.
Br)are Sr
1 "
ce CSFA060300
NELSON A SH1FFLETT
PO BOX 60627
FLORENCE'NIA-014)62
09/22/2014
C/i ii ///1 (17
f•-; telf-fy el;1/.4e
Office of Consumer Affairs and Business Reculation
10 Park Plaza - Suite 51'70
Boston, Massachusetts 02116
Home Irnpro‘ement Contractor Registration
Registration 105543
Type. Pnvate Corporation
Expiration 7/17/2014 Tr# 226093
VALLEY HOME IMPROVEMENT INC.
Nelson Shifflett
P.O. Box 60627
FLORENCE, MA 01062
Update ‘(ftiress and return card.Mark reason for change.
Address Renewal Employment Last Card
SCA I O-Y
SECTION 8- CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shif f lets' _ 0603 00
Valley Home Improvement, Inc. License Number
_340 Riverside Drive, Northampton, MA 0.1.06_0 9/22/0
Address Expiration Date
584-7522
Signature Telephone
9. Registered Home Improvemen Contractor: Not Applicable ❑
Valley Home Improvement, Inc- 105543
Company Name u Registration Number
340 Riverr.ide 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- llil 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 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
, •rSTiON 5. DESCRIPTION OF PROPOSED WORK(check MI elp,pilotrit)
New House L.1 Addition U
- Windows .
, Replacement Windows AIteration(s) D 1. Roofing 11 i
Or Doors
( Accessory Bldg. ° ' Demolition° New Signs - J Decks '', I Siding I I Other : I
3-1c Dc-e,u-17.): or te! rir(13•Of■eC '‘“->*k Peekfrri 7 0.11.1(111‘11. 141‘.641. A)de 144-1 c (,,,y ..5Nr it),..)041,4
— ,
4e.p0}...F a 4 a fr40. 9e e4
,,-...rin -3' ,t,y14,:trtp hr-trfortorn Yet; \Jr/ A r.:1 I9p, neoeflefirco-t"
..-t,:itLiie.t.' No-rAth.-...4 riehjvofr,g '..i1 t,Ife:1 itt.t.tetrient Yet, !lc
..`t.t.:aPhed Put S-ivet.
6a. If New house and or addition,to existing housing, complete the following:
1,f,E., :-..tt Duilcit-4, . C'e 7 am 12,0 Tv.3 7 arndy
' b I%,Jrnbei 1`;' fCS, .1 teach .31-1:y tteit: Virin÷.' 07 1.:'';:itatrafcm.5'
t.., it,
1 :1 rie; t.r..1.1., Sdu,trr.,' foomit:e t;Itiew ',.(.;iittr,,,Ct,D11 :).1•:1,91,z.,R.,..c,-
,:,' 7•21*-r''' 15! ".;',-: S
4. Ve:r-di i.::` hdoPfte i 1-t-4: ftf2t,v., :..J. Wev...1;...triti-4-, Nu-- l'..te- V UOCII
, 2 E-erzy Cc-serva:icn Oor-p la-Pc .,„.„.....__ rt.latectTck EfteTyCprn.aettpe form a:tact,ca?
of cc-t,Iti.totich
• ',..co-rAt, 1.1ciit-4bltiti I 0:::' 1 Of "e.:_t,iricr:S? Yes Ne. I:, cf.thstrucf.mi vv :tit" IOU vi 'le-,:,,:ila it I
1
of :1:3'en-writ ,:'%! (:4. r Lf)Or ;)itiOeo 'Ir^lf,./led ZI.:1C.E.,.
k "N:1; otrith-g f.x.t-form to :he Pttltioing t-eid 23t-or,21-eit....latic-`.4'.? Yat:, No-
f
!. SevtiC 7atili C 7.y `-:-:ev,-(71 Pt vt:t*,.it v%e'l .....„. ,.,„. City ter
SECTION 7a . OWNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,
.. tn t-a,ci,_4(ykan _ .
, as J..4...rier(..4 .-a Luts-ct v:k-.Er Po
-
1-itItty ,:if-..r,hrt7e. _Nelson Shif flett, Valley_ Home Improvement, Inc. ,
rri,. t.:,...- 'it!! 1 -- ettt.t.4.ft., -eR...t,o-, b.,: ..)1.. -1.111te41..,et, ty thi.S Ltu o 112 ,:tt'tt -t*, ahritt-..,:tv, I
-
,1-<.- ' Si' d- 1 13
• e1son_Shitf1elt4..__Valley_liome_Improvernant,, Inc. , ;,,, '.....;w1),,,c/Affirtry1761 iteiti'lt
hrrrty driciair thar. -.--td tatetricht.....,. erld irtforr- ,it; itt 0.1 the foiregoir g 0 or Lcotiott ,t,re :me ciftd ituz;or,1.1x, so :11e 1:e:z,:. u it iy
krewidcpe and belief.
the :.)--..1t-.,.: e4-4...i pa-tiitit.-.i. Li'
Nelson Shif f let t
r t rs.,:,11•1,,
1 4 -/7- ?o'3
, ....
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
:(/14
Side L: R: L: : �1/
— Rear `� c•/il
Building Height / !�-a
Bldg. Square Footage l °��(
Open Space Footage `P O'%\\
(Lot area minus bldg&paved Q 1-(e
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO t7 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 I-- -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:
_ � r i f ,
._. . , ', Department use only
I$ :'�� City of Northampton Status or Pert: .:
203 Building Department Curb Cut/Driveway Permit
�� 212 Main Street Sewer/Septic Ava�la 3 lily
Room 100
�gpzct�ons W �r/Well Availability� � � � ��� �"..cto,
Electra Nortrla Pg' p',F"cbe orthampton, MA 01060 Tv Sets of S rUctural Plans
phone 413-587-1240 Fax 413-587.1272 Plot/Site P4; 4 �'' ,
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
,37 C-( 'W '(CC A LS Map Lot Unit
Ala /�/! p%./ / 41 Zone Overlay District
Elm St District. CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
:FQn
1-6 c k wrt ct,n 3 ? Pro c- - fir/c h lS , /wd a, k'
Name int) Current Mali cadre s; f G�5
Telephone
Signa
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc.,_ P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
2/4 !e1 584-7522 —_ __,_-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use Only _1
completed by permit applicant
1. Building /-j., J (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 5) , Oil 3/62) 30
6. Total = (1 +2 + 3 +4 + 5 /5; Check Number
This Section For Official Use Only
Building Permit Number: Date Issued: .—
Signature: --
Building Commissioner/Inspector of Buildings Date I
i
'PROSPECT HGTS BP-2014-0337
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 177 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2014-0337
Project# JS-2014-000574
Est. Cost: $15000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 18992.16 Owner: HACKMAN JANET T
Zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 0,7 PROSPECT HGTS
Applicant Address: Phone: Insurance:
P O BOX 60627 ll (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:9/17/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 9/17/2013 0:00:00 $35.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner