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TO BE CONSTRUED AS AN ACCURATE SURV
BUILDING LOCATION ACCURAC'i
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BOOK 4976. PAGE 3B
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DEPARTMENT OF BUILDITNG INSPECTIONS = t
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ��" t�s"�
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, si-vc,V SILrl/ c.f?/�'Li ( , OfILLFI t/A4E ,i d `. 4iif/tC.
(IicenseeJpermittee)
with a principal place of business/residence at:
.; v 4i'i$i_s ,�/i- /Lf--7/ rlii/T/7,7,44 (phone#) .5-X-6/-7,5"z2-
(stre t/city!stalhip5
do hereby certify, under the pains and penalties of perjury, that:
0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additionl sheet if necessary to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do maintenance construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally can idered to be
employers under the worker's compensation Ad(GL152,ss1(5)),application by a homeowner for a license or permit may evidence the
legal status of as employer under the Worker's Compensation Ad.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents'Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a$me of up to S1,500.00 and/or imprisonment of up to one year and civil pemkties in the form of a Stop Work Order and a
fine of 3100.00 a day against me.
Signed as day of �;"J V� 1^� -2,03 For departmental use only
,� Permit Number
i!/�'�1`7j/' i I / / /ti/'j�% Met Lot#
ignature of Li..: `ermittee
•
qn,frrur; Stzpr rs.,:,r I
CSF A-0 603C0 .
TVZ":4:1
114,1'
NE LSON A SHIFF LE f..14,0„
PO BOX 40627
FLOREN CE 04244
t t an°rl
.-.41-rra 09,22i2014
ek, /
„Jiff' 1/177i'01,17( (;)- / j di I/
0 nice ol Consumer Affairs and BlISMCSS Reaulatwn
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
RegistraPori: 105543
Type: Prtvate Corporation
Expiration. 7/1712014 Tr 125093
VALLEY HOME IMPROVEMENT INC„
Nelson Shifflet
P.O. Sox 60627
FLORENCE. MA 01062
pdate Vddrels and retura card,Marti. reason far than .
Renetcal Employment Lt t -,trJ
f. 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 Dri.me, Northampi-nn, Ma 01060 9/22//:=
Address Expiration Date
584-7522
Signature Telephone
Regtere 'Horiie 1proverment Contract +'r Not Applicable ❑
Valley Ho � I�aprove e `, Tr '_ 105543
Company Name Registration Number
340 Riverside Drive 7117J]
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 !10 No ❑
1 . Ronnie ( Il�er..Egempio
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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,r:Tt-,ON 5. DESCRIPTION OF PROPOSED WORK(chattk aft ar,. ■,..p2dotIlf.z) 1
—11 ,
Now House :::: 1 Addition 0 TRe;IL;rnent Windows i Aaeration(s)to Rooting 0
,
, ; 1 01 Doors 11:1 1
t
! Acce-:ssory Bldg. 0 l' Dermtliticr0 Ilev.,. Signs ; 1 Decks ; 1 Siding( 1 Other
,-._._.-- ....._.--.....=-...._.................-7.----=.--.,..=..-....-__-...._ -' ----- _
5-!,...,' EIVIC-LY.:On Of r1CP0f;(1C 'INe'ic. L C'A'Ar A IN 4 6 4 0 ilr veil N ctt/ d_VA';4 6.6.to GE' (Ai•Prt-
: it i i,4 rover e d P4 74.d
o' (t)•15!,!sli,:-.; :3(.1r.:faCill Ye:f., No Aciale, fl . bertrcCtr, \i`es No
AA:adieu Narrativt Re ;tri,;:)1.0.-inr.Altri. t:,„:1int,..-.-.t
Pla-.5 AttDclied Rol; • !..-21m...
G . ii New house and or addition to existing housing. complete the folloWincr.
0.
' a kJ::,e !at i:)utica: : Cf,e, :-StIlly V To Family Ot -,:-Ir
_.,—.,...,_
i
I
b INome.r ct rooms in each randy unit: Nurnt:er of 1-.c:ztrircoert$ —
G. Ir, tnere a garage attached? A/40
1 cl P!opo.,,eic Souare lofotage f....2 new construct:on t3 al_ (0/0-2t>1-4...nsocilf, o? 4')e2 to ti)1GIL /2001v4_icr
I
t. method of healing? A) /./.. rrec:f,,s- or Woodstoves Numb e-t of each
/ /71
c.-:. F.rerzy Conservation Compt.iace-. Mascheck Erv.rgy Compliance form attached? —
1;ypt,,ot ccllucticri _
_..,..........____
co!1:1,t11.icsi within 100 ft. of?...etlites? is No. Is,construction wp:hir 100 yr. ticodplain Yes No
i. DCV.1.1,1 of.basementor cellar iioor below tmtshed grade
k. Will Ourlding conform to the Budding and Zoning regulatiort-f;? Yes No .
I. SeCtic Tank Cr,ty 5w1' Prwate welt City o.ater Supply
SECTiON 7a -OWNER AUTHOP,IZATION-TO BE COMPLETED WHEI4
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
— —
... .A.AailQa,0„1.--a k,ktitiSIC as Owner ci ne subject property.
hereby alitrinri7e Nelson ,Shifflett,,, y,Alley gorne_Tnpr,oyentent,,_Inc,.____ __ za act on
my iseitlf. .• d',I r`I‘'ttefs reLati.e to work autho•i2ed by this bdmp.ilif..-Irrit a ZsPliCatiGn.
1 4a
— _........—.....
SiR1131.17,Ire OT 06.-41er / Datc
. .., . ,
- • • -' # - - 1 ayoneIn! ov_eraent. Inc. , AS OWIler/AUMOr176C1 Ant
hereby doclarc filat. :he-statements urid inforr,TutIon on the foregoirg atiplicatich ii!re teue and accurate, to We Lilts: of my
1-,:rowleosle end belief.
iSig,--,ed ...;nde• thi: peAn's ard pcnalticts of peritv. ,
Nel4Pn_Shiellett F,
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF liNFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
.— Building Department
Lot Size La;GOo ia; (,6
Frontage /De. /496f•-1
Setbacks Front co' SO
Side L: a? R: 05' L: ?) R: v
Rear 110371-•%0 wf
a 90 ' 3
Building Height
lG 'C
Bldg. Square Footage )316 % c) 211, .D5
Open Space Footage
(Lot area minus bldg&paved yG� 96) 991/CE �,
parking) u /
#of Parking Spaces 3 3
Fill:
(volume&Location)
A. Has aSpe/cial Permit/Variance/Finding ever been issued for/on the site?
NO V DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO (77 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
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 V
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:
Departrrient use only ,I
1 i �/7 itv of Northampton StatusofPerinit
p ll C E �L _ rs
:cuilding Department Curb Cut/Driveway Permit,
212 Main Street Sewer/SepticAvaileos tty
- SEP 3 Q 2013 j 4 Room 100 Wa#er/Well Availability
`� '.rthampton, MA 01060 Tn%o Sets of Structural Plans
N
Electric,Plumbing es. 587.1240 Fax 413.587-1272 .Plot/Site PIaias
A 9 I .-cti. s r .,
Northampton, MA 01060 Other S eci
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
fJtfl a CMJS75N G (4i/3.e
`"i" ov;I d �G L� A 0
y ,<. ‘01-4-14 ti • llA 8 'X )6 ' la � `°
SECTION 1-SITE INFORMATION
1.1 Property Address: This section to be completed by office
1 \ k04-h Oe i°� Map Lot Unit
Zone Overlay District
Elm St.District ,;CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-Name Current Mailing A`d�dr/ � 520 w �g��
-�/I Telephone
Signal I
2.2 Authoriz-d Agent: Nelson Shi f f l e t t
Valle Home Improvement. Inc. P.O. Box 60627, Florence, MA 01062
Name(P nt) Current Mailing Address:
A
7) / ,/e Gf-//'a0i..3 584-7522
Signature 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
4/,S,P06
2. Electrical (b)Estimated Total Cost of
S-0o0 Construction from(6)
3. Plumbing Building Permit Fees
14x 0/16//d019
! J'4��€7
4. Mechanical(HVAC)
5. Fire Protection �yf
6. Total =(1 + 2 + 3 +4 + 5) S-01ODc� Check Number 3 I�d� �136ro
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: --
Building Commissioner/Inspector of Buildings Date
5-r
6
3V c)
File#BP-2014-0375
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 131 NORTH MAPLE ST
MAP 17A PARCEL 207 001 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 7
Fee Paid 3174Z HIV
Typeof Construction: DEMO GARAGE&CONSTRUCT 24 X 26 GARAGE W/8 X 26 COVERED PATIO
New Construction Re OA
A
Non Structural interior renovations 'V O
Addition to Existin .h%1/ /f!
Accessory Structure - A C�0 '
Building Plans Included:
Owner/Statement or License 060300 p n
3 sets of Plans/Plot Plan �`"'U5
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO PRESENTED:
pproved 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
ePP
'rture of Building 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.
131 NORTH MAPLE ST BP-2014-0375
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-207 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: GARAGE BUILDING PERMIT
Permit# BP-2014-0375
Project# JS-2014-000652
Est.Cost: $50000.00
Fee: $300.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 49222.80 Owner: WALDER MARTIN J&JOAN
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 131 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:10/2/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO GARAGE & CONSTRUCT 24 X 26
GARAGE W/8 X 26 COVERED PATIO - Ivl,truss & braced wall solution before rgh insp
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 10/2/2013 0:00:00 $300.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner