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--- DEPARTMENT OP BUILDITjG INSPECTIONS 4 k __r
212 Main Street • Municipal Building
Northampton, Mass. 01060 `'��:
WORKER'S COMPENSATION INSURANCE AI'rwAVIT
I, Nelson A. Shifflett / Valley Home Improvement, Inc.
(licenseepermittee)
with a principal place of business/residence at:
t'v '.- • . r orthampton, MA 01060 (phone#) (413) 584-7522
(cteet/nit•/st,teJ p) -
do hereby certify, under the pains and penalties of perjury, that:
Col I am an employer providing the following worker's compensation coverage for my
employees working on this iob:
(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 workers 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 homeowners who employ persom to do tnair,tPrixerr,construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the groins appurtenant thereto are not generally considered to be
employers under the worker's compensation Act(GL152,ss I(5)),application by a hotneowrur for a license or permit may evidence the
legal status of an employer under the Worltds Compensation Act_
I understand that a copy of this statcmecc may be forwarded to the Depart:moot of Industrial Accident,'Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOIL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisoe meal of up to one year and civil penalties in the form of a Stop Work Order and a
fine 0(5100.00 a day against me. //JJ
Signed this 07 day of /� 't/ ' dad 3 For de of use only
_ . Permit Number
W „ , , �l 4M, Map# Lot#
Signature of Li.••Pr •ermu• .
_SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson ShiffletRt 060300 -
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA Clin60 9/22/04
Address Expiration Date
584-7522
Signature Telephone
--I H.me Im"•v=m- ac s Not Applicable ❑
Valley Home Improvement. Inc. 105543
Company Name Registration Number
340 Riverside Drive 7/17/04
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 22 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
•
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ 1 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing c
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: ,tj I ( 1 J
Alteration of existing bedroom Yes i/ No Adding new bedroom ,,��/ Y No
Attached Narrative _ Renovating unfinished b�sem;efr Yes No
Plans Attached Roll _ - Sheet 40
6a. If New house and or addition g-hn to existing-housing. complete the following:
on
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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 100 ft. of wetlands? Yes 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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
//5. 2 /L—L. , 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.
gt--34,1 62-)teAV /0/TA3
Signature of Owner Date
I, 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. 2
Nelson Shifflett 71/ '1 °l/
Print Name 4 /
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
L: :
:
Rear 1)\
Building Height 00
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 I/ 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 L - 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
Qi'ty of fNlortampton Status of P rr it
Q21 Building Dep rtment
Curb CutintiveWaylogrut-
reet
Sewer/SepticAyai(ab�(ity
atir *, ' R orfi` 100 W I/Well Avada6iltty a �� s'�.
,� -q°4-1tIiiiiampton, MA 01060 Two ets of Aral Plans
p1one'413-587-1240 Fax 413-587.1272 Pl(4/Site
Other Sped.'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
•
SECTION 3.-SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
/ ),/f 610 5-3 Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �> j-3-
SdfJ/t,V D '✓lZl� /Ac , 7,./ /0 3
Name(Print) A-10 v, ( ) LI_ Curr ilin
Telephone
Signature F--r ti (�71-C--4-A‘1-C- --C
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
Aor/,�1 584-7522
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 1 Official Use Only
completed by permit applicant
1. Building ?/,57, (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 + kip', ICJ 1l rl
( , r �•.S r Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2004-0512
GIS#: COMMONWEALTH OF MASSACHUSETTS
:fl kter zY �ti".s` CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0512
Project# 3S-2004-0725
Est.Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sq.ft.): 31798.80 Owner: O`NEILL SUSAN F
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:10/28/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR PORCH ROOF
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: Receipt No: Date Paid: Check No: Amount:
Building 10/28/03 0:00:00 17234 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo