11A-070(1) �a.R��: )4 e lL t�1 of Nazt�antptatt l am__
g .e to 3 4 _s
y�l .�.�(!j• Massachusetts s= '_
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street • Municipal Building �g
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Nelson A. Shifflett / Valley Home Improvement, Inc.
(lrcenseeIpermittee) __...
with a principal place of business/residence at:
220 P,ver aisle _Drive, Northampton, MA 01060 (phone#) (413) 584-7522
(strn^..t/cit=/statti-i p)
do hereby certify, under the pains and penalties of perjury, that:
(X` I am an employer providing the following worker's compensation coverage for my
employees working on this lob:
American International Companies WC 6554540 00 02/01/2002
(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) (lnsarancc 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 ooreractors)
( ) 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 maimcmac;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 considered to be
employers under the worker's compensation pct(GLI52ss I(5)).application by a homeowner fora license or permit may evidence the
legal status of an employer under the Worker's Compematioa Ant
I understand that a copy of this statement may be forwarded to the Department of Industrial Aoeideess•Offioo of Imruanoe for the
coverage verification and that failure to seine coverage under section 2SA of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 andlor imprisonment of up to one year and civil penalties in the fora of a Stop Work Order and a
fine of SI00.00 a day against me.
Signed this 9 day of /J , 2001 For dcparunrilal use only
fPermit Number
.� _ ✓� 'J�i"'` 11 Map# Lot#
Signature of 1,-....0755•ermi r .
I•SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Nelson Shifflett 060300
Valley Home Improvement, Inc. License Number
320 Riverside Drive 9/02
Address Expiration Date
Northampton, MA 01060
Signature Telephone
"tr- 584-7522
II ��1 �e:LE�i°�.r ,t! Not Applicable ❑
Valley Home Improvement, Inc. 105543
Company Name Registration Number
320 Riverside Drive 7/17/02
Address Expiration Date
Northapton, 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 No ❑
11. - Home Owner Exemption,
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(sl
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
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ I Addition ❑ Replacement Windows Alteration(s)% Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ 1 Decks [ ] Siding[ ] Other [ /
Brief Description of Proposed Work: bat )41.40 t)'.1`if/c of f a%Gr7v)`/ digh gap 4//411/04/ ,�IJC/13yf
Alteration of existing bedroom ____e/Yesi No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _-__L,./No
Plans Attached Roll - Sheet i/-
6a. if New house and or addition to existing housing. complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms________,
c. is there a garage attached? /t/
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? Z
f. Method of heating? C/7i/ii Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance._ J.//9 Mascheck Energy Compliance form attached?
Type of construction f 3
i. Is construction within 100 ft. of wetlands? Yes 1-/-v-No. is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade /�
k. Will building conform to the Building and Zoning regulations? Yes_ No -
1. Septic Tank City Sewer l/ Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
;. Susan O'Neill , as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement, Inc. to act on
my behalf, in all matters relative to work authorized by this building permit application.
Cie
Signature of Owner Dat
Nelson Shifflett, Valley Home Improvement, Inc. as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name
4)i
Signature of 0 /7/Agent Date
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 he filled in by
Building Department
Lot Size �I:
Frontage 6Z)
Setbacks Front c�,
Side L: L:r R:
Rear SV
Building Height fv ( 1
Bldg.Square Footage `6 %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) _
A. Has a Spefial 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 D J9OW 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:
•
$ a�
City of Northampton -
ilding Department Cul `� �a
1i2 Main Street power,
lyettrot-
1 7 om 100 k is
SEP 2
n 2[3rth 4 n, MA 01060
phone 413.5 - 2,0 Fax 413-587-1272 #'4t0` / _ `
^rar OF BUILDING INSPFC:rinNS
APPLICAT4 MPTI4` " .14: • TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1j.1P Address: This section to be completed by office
S'3"�roperty E. Center Street Map fi Lot 70 Unit_
Leeds, MA 01053 Zoner,,adi L Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 15 E. Center Street
Leeds, MA 01053
Susan O'Neill
Name(Print) Current Mailing Address:
C� 586-4285
Telephone
Signature
2.2 Authorized Agent: Nelson Shi f f l et t
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01.062
Name(Print) Current Mailing Address:
584-7522
Signa ure 11' 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
6;001 Construction from(6)
3. Plumbing /t 9 Ca Building Permit Fee
4. Mechanical (HVAC) '
5. Fire Protection i
6. Total = (1 + 2 + 3 + 4 + 5) %C 7Q Check Number / 1103/
This Section For Official Use Only
Building Permit Number: 11' �� Date Issued:_____
Signature: ___
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0350
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P 0 Box 60627 (413)584-7522
PROPERTY LOCATION 53 EAST CENTER ST
MAP 11A PARCEL 070 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /54)(3
Typeof Construction: COMBINE TWO 2ND FLR BEDROOMS&ADD BATH&REMODEL KITCHEN
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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
' O ./ z Ly
Signature of Building Officia 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.
RA$T,CBNTER$T: BP-2002-0350
GIS#: COMMONWEALTH OF MASSACHUSETTS
vatginock.11A..O7O CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2002-0350
Project# JS-2002-0529
Est.Cost: $40000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq.ft.): 31798.80 Owner: O'NEILL SUSAN
Zoning:URA Applicant: Valley Home Improvement, Inc
AT: 53 EAST CENTER ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:10/1/01 0:00:00
TO PERFORM THE FOLLOWING WORK:COMBINE TWO 2ND FLR BEDROOMS & ADD
BATH & REMODEL KITCHEN
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 Si¢nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/1/01 0:00:00 14031 $125.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo