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31A-282 (3) . e .I„:CttAMP7. $Ao C1LZ4r Ilf Nt rfl & 1tp±ATt � =**_ tr•�0 6 ;�i'/ 0: �(j+ Assaxc}Itrsrtfs _'at_ w �' } DEPARTMENT OF BUILDING INSPECTIONS Qqr.-------• 212 Main Street ' Municipal Building —y,y Northampton, Mass. 01060 ow 1 WORKER'S COMPENSATION INSURANCE A F] WAVIT L 52-I!/ A, 5/1r I/be/n/7w , i*ZGL,(' //tA E .i 4 ttz4 JAG LC_. (licenseeJpermittee) with a principal place of business/residence at: 3Y-4) 4v" 1.5 A- �..�/zi k-.- -- ,, /- ))j -7'27 t, (phone#) j /-752.._. (streat/citylstat:'/ip� 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 Daze) (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 maintenance,construction or repair work on a dwelling of not more than throe units in which the homeowner resides or no the grounds appurtenant thereto are not generally considered to be employers under the workers.conversation Act(GL152.s 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Worker's Compensation A . 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 fine of up to S1,500.00 and/or imprisonment of up to can year and civil penalties in the form of a Stop Work Order and a fine of 3100.00 a day against me. signed as' 1 day of 1�:;;( it k\ -26))_3 For ,tae only ,, Permit Number - �//f / ./���'�' /- i.r % Map�t Lot# ignature of Li.... `ermittee • -Sufwr, CS FA-06,0300 NEJ.SON A SH IFF LE PO SOX 60627 FLORIN CE MA.(11i142 , 09/22t20141 te-et-tret14 r "074 talk (.. ittL /(hit.,e /7.) tv.Wjk.!=:1 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration RegletraPon 105543 Type. Private Corperation Expirabon. 7/17/2014 Tr ti 22eC-93 VALLEY HOME IMPROVEMENT INC. Nelson Shifflett P.O. Box 60627 FLORENCE, MA 01062 pdat, vddre.13 iud return card, M3r 1.rrnsun fur rhange. os., Renew 31 Employment Loq'1 urd 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 Drive, _Northampton, MA 0060 9/22/f Address Expiration Date 584-7522 Signature Telephone '�. Re stere "Ho e i ovdmertt on racfdr Not Applicable ❑ V lley Home Istt y v Inc 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 lilt No ❑ IL*Illoteit-4080ittEielifintilin 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 L rws Annotated. Homeowner Signature ' ,-,C1-teN 5. DESCRIPTION OF PROPOSED WORK(chet,-k nll aripjacAlip) ' , . I._ - _......._ ....._... 1 New Hot4e :.-.1 I Addition 0 Replacement Windows 1 Xteration(s) 0 Roofing 0 i 0/ Doors Accessory B;dg. 0 DIR:lc:F:17 New Signs : 1 Decks : ] Sidicg t; 1 Otte, , 3-1,:-.' Dc:x.:-1;:e.:on lot rr.:;:pof.,ec .'itc.k. G /00 S. / ...Lig - ae PAT li C4..sin ilc3 I 3, (:KiV,A117 her:sc.4.--,:m Ye..F, Nc.; Ao1;ng ri,...../:negst:norn `te,3 No 4..ttached Narratr,',,, Reno.,,,-.1tr,,:-;:JitfinOle,,i. Fx--; Attached Pc .-• 5.-:-'leet : 62. li New house and_or addition to existing housing. complete the following: a iii.6 :.".4 Dullairii: : Cfle. ::,'ItIlly ,, Two Farricly Otr .. i t f b Notroer ct roams in each tamiiy unit: Nu.,-- nz, or 1 G. ft, tn ere a gtvage attached? ,., I u v- c.a.,,ec Sur e It-.;(44..,,,, °I new constructjon Di'nen:sic:4).s st(;'is'„_______.........._..............., ._..._....,.............._ t. !'Acthoi of heatrhg? rrept.eoeti or Wcv.P.A0vel5 Numb e! of each E. Enerzv Cc7servaticn Compdarce. Masetteek E.,nergy Cornoltance form attached? t oc---..structicn crytt,..trijc-,tidn within 1o0 rt. of wece,::0Cs? is No. Is constructic.m wtthir 100 yr. tloodplarn Yes No . DopV.1 of.bw.,erilent or cellar tloor belov., tshed grade . k. MI building conform lo the Building and Zoning replaticrts? Yes No . I. SeCtio Tank Cety Sewer Pill:ate we11 City water Surfs . SECTION 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT SkLtL , as Owner ci tf-,e subject property, hereby illiZr° rt7E.: Nelson_Shif flett,,_Valley Horne_Improyement,_Inc,.„...___ to act on my bc.,lt, . Irt A rnattef relative to wortl. authori2ed by thIS baildng permit a.aplication. siRna:r.li-2 or Oe.ler Datc - • • -' -4 - - 1 - _liorae_Impx.oxement.tne. , as t)..tener/Autnorr7ed Agent hereby dcoh.ge t.;-,i1^. thc-.3tatorricrits .crid inforrlDtlari er: the foregorrii traplit.: tion :Ire true and accurate, W thet>est of my krowlotge End belief. Sig.-ted :.inde! ti-74.: di-ons ard pc.nultics of perlUrY. Nel .ori_Shif.f.lett Prirl NarrA:____ • ,4 / •.,0) e ?0/5 . SOr.&::Ji'm o: c‘,..7-ie•-•Air-z1/ Dail:: .„..._. . . - 1 C �dd Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF ENFORMATION 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 ,/� it)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 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: Department use only _ ' v of Northampton Status`of Permit nn rE---i, c ir--'_ I '',:',' l'-', f-Ai'Iding Department Curb Cut/Driveway P rmit 12 Main Street Sewer/Septic Availaafil hl ';, i; ty OCI — 7 2��3 Room 100 Wat tiWellAvailability , am ton MA 01060 f' r , Not p Two Sets of St cL ,:, Plans (j{ -587.1240 Fax 413.587.1272 Plot/Site Plans Electric,Plumbing&Gas Inspections Other eCl x+ Northampton,MA 01060 p '' " APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S7ci,p, °I/ 4 i„ £oJW c )c go P I SECTION 1-SITE INFORMATION gl6J•`ld c4te a t ///tf A ',6 Tits section to be completed by office 1.1 Property Address: l©0 tJ4 jAr •5 ni 4,tr Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1 7, ,_. ,,),„_, ,s u.t u gf U-t.e_(- (� 1 `(fw� �u...e, i 1�.��'t ,►-p'(..., c l o(,o— Current Mailing Address: fti■-..--�\(`')If\A I '-- Telephone Signature 2.2 Authorized Agent: Nelson Shif f lett Valley Home Improvement. Inc, P.O. Box 60627, Florence, MA 01062 Name(Print) Current Mailing Address: ii /1 Ckillt0P----- 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 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) feet, Check Number ji 7' '55 This Section For Official Use Only -- Building Permit Number: Date Issued: I Signature: Date I Building Commissioner/Inspector of Buildings 100 WASHINGTON AVE BP-2014-0422 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A-282 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2014-0422 Project# JS-2014-000731 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 29098.08 Owner: KORFF JEFFREY M&STEUER SHELLY Zoning:URA(89)/RR(11)/WP(8)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 100 WASHINGTON AVE Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:10/8/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE SOUTH SIDE ROOF & REBUILD CHIMNEY FLASHING 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 10/8/2013 0:00:00 $55.00 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner