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..,._ DEPARTMENT OF BUILDING INSPECTIONS
• .‘ 212 Main Street ' Municipal Building -....-.... — -
Northampton, Mass. 01060 ow"
WORKER'S COMPENSATION INSURANCE IDAVIT
i
t' 5/L1/61.1614/1-Zi /, Z.Z.. . F''' /7671/i
' (licensee/permittee)
with a principal place of business/residence at:
3 .4) 1:61 .,&41-L' . /- 777-7177//-27-yz 7,7/4 (phone)
(str=t/c-ity/stattheipc
do hereby certify, under the pains and penalties of perjury, that:
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 additiceal sheet if necessary to include information pertaining to all contractors)
mINOTE please be aware homeowners en2P Pcmat mAirdemace.'axatrwti cir=Pair work on a dwelling of
( ) I am a sole proprietor and have no one working for me.
( ) I al11:0 a horn.ei ownwhiler:perf7e:isalltthi:work myself
NOTE:
not more than three units in which the homeowner resides or cat the grounds appurtenant thereto are not generally considered to be
employers under the workees compensnica Act(GL152,:s1(5)),application by a homeowner for a license or permit may evidosce the
legal status of en employer under the Workers Compensation Act..
I understand that a copy of this statement.may be forwarded to the Department of Industrial AD:idol&Office of Insuranoa for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a•fine of up to S1,500.00 andkc 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.
.,
Signed4;re ctaY or — J( 11/1 1 1-. 5 1--")1---' For depintrental use only
Ar
/Aill Permit Number
AO' Xr , /,/ " ' ' ' Map4 Lot 4
// /
ignature of Li.. :- 'erMittee v
L.Jcpartrnen: ot euplle zsarmy
80.3rd o awidng Realmataons and Sl'amiards
Construcnon Supert/sor & 2 Famik
CSFA-060300
NELSON A stuFFLErt
„ -
PO BOX 60627 •!.y.r 31,7 f„
FLORENCE MA70106.21i41
..,141,614*** m
Cornmissionec 09/2212014
f ,() (221?ef
// /
tyj fey Je,
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration.: 105543
Type: Private Corporation
Expiration: 7/17/2014 Tr# 226093
VALLEY HOME IMPROVEMENT INC,
Nelson Shifflett
P.O. Box 60627
FLORENCE, MA 01062
I pdate Address and return card, Mark reason for change.
Address • Renewal - Employment . Lost Card
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shi£fett 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Nort]saMpd-on, MA 01,1160 9/22//+------- ---
Address I Expiration Date
// //07!1 584-7522
Signa ure Telephone
9, Registered:Home.Improvement Contractor: Not Applicable ❑
Valley Home Imp . vement. Ins_ 105543
Company Name Registration Number
340 Riverside Drive 7/17/1' 4
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 !ifl No 0
1 . - 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 itt 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, von may be liable for persons)
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
TI+N . DESCRIPTION OF PROPOSED WORK (check an aRptisaltio)
Now House LI Addition U 1 Replacement Windows : Aletation(s) c: I Roofing r
ar Doors :: r
Accessory Bldg. , Demolition:3 New Signs ' ) Decks '.. ) Siding [ ) Other
— _
1.)ri Pr.f., 1.:C „.1C Afwrk Thso lake_ catic LAI to" cellikscseal due/5 4inc14-4-te air sk-cti it-
,n.,:::, hrl(: c..4^;.101 Yil“: )(Nr, r4t A rR ri..4.7: nill•nr..-- N 1,..,"; >, ...1'-ir, I
t.„*. %Lr r,;..t,ttvt. p,,,,,,,,,,T,,,Itr i.: .„.ligr-n...itoj
F°13--... :..ta:ilt.."-: 1-7-ur
6a. if New house and or addition to existing housing, complete the following:
C C ra.rn ,/ Tv.-.7,7,7,11-111, 1:)!--...f _ __,_
1 e71,-:11 .5r" y 1' t 'V i—c.":-E' f'.* ','-",--",t,1""r:C 7•,-,F ,
.V`L"?..0e.e?
,,it :-.;■;.::.%It7. `c.,.. 1,1w1. '', 11,Flw -.....r.,'t,.1I
'',* %: 1- 1:-.. :,! -' .•=,- .,
I VeC',..1 '3‘ 'fi:;..0. 'ri i l't71.: L,_tt. ...,I Wi.:,..X.i.,tl...',,,-..-.., Nil!' 1.`,...:"' [..,‘ t,.:..-sch
' .. ,r ,y Cr:- ..,7.r-v<7,_:?C.-: `.....Dr-r; ia-:-. . MEE,2,f,12,,:k Enfrgy C:rtc,DI,Lli:(... 1-31-rt 3tti.ci-cr2
:-.1- :t
• '",.) ,.. .. ('1 Vi,th 1 1C 1 .`,iot ^e„e, ;=.11#,-;s? .__°*:P.Lis ',17.: ii, umistr ar.:t..,011 %-. :00
:•tt t7;1,,,,r[tflol ',•.',.. cf.rr t:,or ,..',(,,Inv,,, '1,,t,,rteil ;.21,-ieLf,
!
;, w,l' au 1,firi, r,o,r,.:Itm to .ht..! ktik.lrip, .::od ? nE 1 4,..1.1tiC'f,? 1".:,..t._ N.t)
. al..11c 7 .1...4:, C `,y :,-*.e-H7..t
A
1 SECTION 7a .OWNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
AU.As Ket. :\i . aS ::.P.,."tEt Ci '. . -i.t.IL!etri.
tv,- I'v ,'.1.1`;r4f);IN,. Nelson Shif flet t, Valley Home Improvement, Inc.
m,,, L'......-:',11' vt. o 1 --.-:.tt.--t... -tt'.....7+ tu w)1-. ....utitcrriet: ;1,, 1.11.f, b.i t.: ni.; ': .fr,r, rt, .ittr ,•Itic; t
..,ritt 3:Jre 01 Lit,iier
-----
i
_Nelson—Shitilett.__Valley Home Improxemeza, Inc. , ,v, ":,,,,.. rfAill'Wr i71,1 1,E;f-r t
tIC'C't": dCCL'Irr* , .,,,..: .,._.. .L.:titeirl...:.Ittr.. ,..,:nci rforr-tet''jlt 1.!** tilt f"..”VF°:)1riri.:1:11.,q'f, tiC,.■ ,'P.,1 ',rue. ‘.1!,-.,j ;n e,
Lrc-..:1:."...cC, F tic': ttclief
1 „:-,17-,czi ,..1---,c,:- -1-..: :7.):„ -,,,,•. 2,7-....i L-..i-ILI w.:1., ci L..,,,..w.t.,,,...
Nelson Shif flett_ •_ _
, — -
--- - A - /
--
--
r-t;t1-!, fildah 3
_...
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
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 ✓X
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:
n•f Marti-rump-tart
91:q1"1-74,44„
1 r
. ttssttrltusrtts 10,
t � rs� ., s x
DEPARTMENT OF BUILDING INSPECTIONS y ,,
212 Main Street • Municipal Building j�^4
Northampton, MA 01060
LOUISIH
INSPECTOR BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1st floor
.30 " 2nd floor
.20 " " %floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY I!
*Filing deadline is 12:00 pm(noon)on Wednesday.
A
Department use only
r' r`"" \ City of Northampton Status of Permit:
\' Building Department Curb Cut/DrivewayPermit
212 Main Street Sewer/Septic Availability
i ,v, UE- k Room 100 Water/Well Availability
1F,; ......3
-„,..tlo i rthampton, MA 01060 Two Sets of Structural Plans
C '` - ■ .-587-1240 Fax 413-587-1272 PIotlSite Plars
Electra N„rtr,uY Pt:,n.!
Other Specify•
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
-- — -- - -------
- This section to be completed by office
1.1 Property Address:
Map Lot Unit
�':35 pore nee_ �
FlOren(e) MA Ut C)(0Q- Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
)�lo xe_e_n Kt e l y aq Hen*za) AV e_ /VOrTan7p 1 A_
Name(Print) Current Mailing Address:.
Addre s:
LI/3 -& y— �40
0/06,0
Poku Y t o-y1 k /rry n Y / l-L, rtiki
Telephone
ignature
2.2 Authorized Agent:
Ne1scr 5 h le{F 1164 Horne ir-Yrroentcaut g4'0 R1 vein-1cle Da' Florence j
Name(Print) Current Mailing Address:
770 Iti3 -5899, -'75
Signature" Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ;JQoO, 06 (a)Building Permit Fee
2. Electrical "� (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire l=(1 +2 Protection �/'/ 4 ! *(��
6. Total=(1 +2+3+4+5) #11000 • G't d Check Number _
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
NA
File#BP-2014-0685
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 435 FLORENCE RD
MAP 30C PARCEL 008 001 ZONE SR(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3//,SQL! '
Fee Paid ll �N�/
Typeof Construction:_INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 060300
3 sets of P ans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO ATION PRESENTED:
Approved 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
em.li •' Delay
,A,,
4
Signature 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.
435 FLORENCE RD BP-2014-0685
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C-008 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0685
Project# JS-2014-001164
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.): 53143.20 Owner: KIELY MAUREEN
Zoning: SR(100)/WSP(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 435 FLORENCE RD
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:12/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 12/5/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner