38B-171 (5) �5ttAMp�.
$`i ittior i 8 NasaarElnsetta =_
"r:�:y- DEPARTMENT OP BUILDING INSPECTIONS =I_i=
212 Main Street • Municipal Building `sV
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L 52-1 t/Z/V(5/L 1,//7&n,17/ ///)/Z-1. :,'"/ /4174 f . /747, `fritZ/2/ 1-6. .
(l_icensee/permittee)
with a principal place of business/residence at:
9 y-) '/ Z4=5 i.L..., , i ,A-( 7 7 /.-27'/Z/244 (phone#) , q-7
(strcet/city/st to 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 Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additio al 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 on the grounds appurtenant thereto are not generally considered to be
employers under the worker's oompessatiot Ad(GL252,ss 1(5)),application by a homeowner for a license or permit may evidez the
legal statue of an employer under the Worker's Compensation Act
I understand that a copy of this scat mat may be forwarded to the Department of Industrial Accidents'Office of Insurance for the
coverage verification and that failure to secure e 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 one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against me.
J`�
Signed�'a day 02 °6.
? J N U/1�� ��t'-' For departmental use only
,1 Permit Number _
/, A ;/'; , �, /2". 4' ,i Map# Lot#
ignatnre of Li.-,. - 'ermittee ' •
2.;.;'4k4 4 -
Board of 8aing Regutabons ad Standards
Cunstrodion ‘superst%t71 s1/4 2 Fanuis
cone CSFA-060300
eo„
NELSON A SHIFFLETT,R..
PO BOX 60(27
FLORENCE MA-0106e: ;
•04
Ex pi ration
C wrwrus smile r 0912=014
/11 I) et/i(1 /id f-
ftii,),17( ifsof4e,
Office of Consumer Affairs and Business Regulation
-1 I 0 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration' 105543
Type: Private Corporation
Expiration 7/1712014 TO 226093
VALLEY HOME IMPROVEMENT INC.
Nelson Shiffiett
P.O. Box 60627
FLORENCE, MA 01062
Update Address and return card. Mark reason for change.
Address Rental Entplosment Lost Card
A CY
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shif fle.t.t__ _060300
Valley Home Improvement, Inc. License Number
I340 Riverside Drive, Northampton, Mk 010._60 9/22/i- --- ----
Address Expiration Date
584-7522 1�
Signature Telephone
9. Registered Home Improvement Contractor; Not Applicable 0
Valley Home Improvement, Inc.. 105543
Company Name Registration Number
340 Riverside Drive ..._._r 7/1711*
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 1Tfl 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 Zoninp,Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature —
, citcrl 5. DESCRIPTION OF PROPOSED WORK Ccht4k,all applisabic)
New licuse ".._: ' Addition —; i
1 Replacement Windows AiteNation(s) r".., 1 Roofing n
Of Doors :: 1 .
Accessory Bldg. :-.1 Demolitior•-..D I New Signs ' 1 Decks : I Siding [ 1 Other
,y, :11.,:t,stc-r,r, Lar t-t nr: pcstert .`c,•-t, ,,Cil 6,;0/4U/11/ ash,vje j Gil 414.10 A-071.4A
Iffi
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6a. If New house and or addition to existing housing, complete the following:
lc. .,.-bi; C.'-`C 7,7-,r11 tv 7-v.:, 7,-,r,mi.,
L: fq,..:rrItti-tr c* rc,-.— 1 eiirt-21 `51--i y tlt" I
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1
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tlrIttttr-utirt no c•,t.littlr I :tor t-rft.tlftett tr-rchtIld itt,r,ICE,
Ii Icirip, :11-.1 .)::-A-,2 i,..,.g..latic :..? •Y.,.:-, ... 113
::::..1:1re '''',-!-ili, C Sewer Pr vc-,°.,-,:: w•E', i :3:7.y water :E.;o:)i) y
SECTION 7a . OWNER AUTHORIZATION .TO BE COMPLETED WHEN
I
I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_ .... . ,.. ,.... ... ., „ ,..,. _ ,... ....______
---- -Zebia-d116\61e-- H arOffCL- , as ,:104,10 ct t-t:
elspri Shifflett, Valley Home Improvement, Inc. trt.t::::1L6
IT,. Lt- eV' t , t..: 1 --tott,tt• t•t„t -La- trt: -4 tm,ot ctrtthe-tzAtttt: t.t,. Ito., b,,r1 ::: rEit. ,qftt, 1:
i
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1 —141,e1.5011tifilet.tt3 Valley Home Improvement, Inc. ,
i tic L": dc nr" -..,"`,2'. ..-0.2 tt'ttattrrrittt. itlIC tr'f'....'Ir-E't,'OH t.,,- the fur,;•. ttir g ir;,11,..1 tLtrtict., :-Irt,t “utt.... tytd out trrrAtt% Ittr t,htt Lttc.ttt t...t. Iry
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1 _Nelson Shifflett_ _..... __
.,,
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 /1.)
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 f a er 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:
1r
iL/r r-—mac � `�� ; _ Department use only I
iI��� -��, r ofi Northampton Status of Permit
ti ocr - riding Department Curb Cut/Driveway Permit
4 20 3 'l 12 Main Street Sewer/Septic Availability �t
I
Etectnc, Plu,-,n, -� Room 100 Wat:er/Well Availability ..
F.-'rtlr ti r e _
o' t>> ,94 ampton, MA 01060 TwdSetsofStructural Plans ,-,
p o''`'".• -"87.1240 Fax 413-587.1272 Pfot/Site Pima
()tiler Specify ,°
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I
p6e)/d w ,S....0C
SECTION 1-SITE INFORMATION 5/Ifi .i / (DO( 01G-r)
1.1 Property Address: This section to be completed by office
Nctot t3cr -) Map Lot Unit
l Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -,1 , , ^ .
I- h,tollt , . ' aA. Q.. 111!• ..gym �t ►� ...•_e, oil. ^
Name rint) Current Mailing Address: e7 q Cl C/oO
_� �.efi'(--/ 2 t— Telephone Lit —Sb7— 3 {OZ
Signature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA, 01062
Name(Print) Current Mailing Address:
584-7522
Signature Telephone
j SECTION 3 - ESTIMATED CONSTRUCTION COSTS �^
I l
Official Use Only item Estimated Coss(1011arS) to be
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) 300 Check Number 1/45/116 li
l This Section For Official Use Only
Building Permit Number: Date Issued: _
Signature:
Building CommissionertInspector of Buildings Date
17 MADISON AVE BP-2014-0519
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 171 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2014-0519
Project# JS-2014-000892
Est. Cost: $2500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 8232.84 Owner: MAROTTA MICHAEL L&MICHELE A
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 17 MADISON AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:10/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE DORMER SIDING
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 10/28/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner