35-060 59" f rn Z
N _ 03
c' z
$ �
in
► zz -c3 > 0 -1 -1z0
0 �
> 0%
tern +
rn F
rn —
z C C
t- T > '
� -i rn
��ttAMp�•
O O
B� a� lLx� �� �rrz�f�tunt��urt
�iaSais[!laSttla
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WOREIR'S COMPENSATTON INSURANCE AFFIDAVIT
(Iicensee/permittee)
with a principal place of business/residence at:
(phone#} �,✓'A5 2—
(btlt"t/Clty/Sla 7iP
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 Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneaesuy to inc]uile k&onnatioa per%i ug to all oentrad )
( ) 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 pertow to do wintenanoe caasuvcdon or rcpair work on a dwelling of
not mote than throe uads is which the homeowner resides ar on the grounds appurtenant theceto are not generally 000ndatid to be
employes und-er the Worker's oompensation.Act(CsL152,ss 1(5)),application by a homeowner for a Uo =,e or per d may evid—the
legal status of an employer under the Worker's Compematioa Ad.
I understand that a copy of thin statemeat may be forwarded to the Dtgvwxas of Inkssu iel Arai&a&Office of Imurance for the
coveroge verification and that failure to scant coverage under section,25 A of MGL 152 can lead to the impositioa of aimmal penalties
oomisting of a fine of up to 51,500.00 andlor of up to one year and civil penzwes in the form of a Stop Work order and a
fine o(3100.00 a day against me.
/— ��
Signed * ____day Of `� JY� /�t`'� , s)r For 6T=tmeaw uao only
Permit Number
Mao Lot#
ignahtre of Li ermit#ee
............_...... .. ..
of Y'a€ '€ Safety
oa od a v�,� !a mci R°Ugul3`'w.P,s ail+ 5 araa d,
qr I+i rob i't`s tr:eta g?er a.�sr t G°aF, « }'omit;
SF A-0603 0
PO BOX 60627
FLORENCE NtA`01062' a
Ex-o'l ,.fit f-s
rzr€� at r .r 09/2212014
,. ()tf�c Cat Consumer rrter airs and Business Regulation
i Park - Suite 5170
Boston, Massachusetts 0211
Home Improvement Contractor Rec istration
Registration: 105543
Type: Private Corporation
Expiration: 711312014 7a# 226093
VALLEY HOME IMPROVEMENT INC.
Nelson Shifflett
P.O. Box 606127
FLORENCE, MA 01062
Update:address and return card. Mark reason for change.
Addrem Reno�-al Ernph)yrnent Lost Card
,..,,, 6
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction SUDervisor: Not Applicable 0
Name of License Holder: 060300
Valley Home Iraprovement, Inc. License Number
340 Riverside Drime,-Northamptan., MA 01060
Address Expiration Date
Signature Telephone
Val 105543
Company Name Registration Number
340 Rivers-i—de Drive 7/17/11/-
Addres Expiration Date
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with th.�s application, Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
. '
11. - Home Owner Exemtion
The current exemption for'1homoowners" was extended minclude pied [one(l) mvwo(2)families
and m allow such homeowner tonnQuguuu individual for hire who does not possess ulicense, provided that the owner acts
Homeowner:as suncryisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Person(x)who own u parcel o[\ond oil which hc/xhc resides ur intends m reside,oil which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or fiarm
szrumorcs. A person who constructs more than one home in a two-ve:)r period shall not be considered a homeowner.
Such"horneowner"shall submit to the Building Official,on a form acceptable to the Building Official,
responsible for all such work performed under the builldin2 permit.
As acting Construction Superviso your presence on the job site will be required from time\o time,during and upon
completion nf the work for which this permit isissued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter |53 (Liability ofEmployers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable;nrporsoo(s)
you hire\o perform work for you under this permit.
The undersigned^`hnmcovmor''uenifics and assumes responsibility for,vmp��uac� �id�1h�8iuzeDui|dIng Codc, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Bomoo`nner GiQnuturo_______—____________
'�CTIt�M �� �SCRtPTt� CDC PE2€31�":3SEE3 1'eeC�f�K (�:h��� �tti �ots�ili� E�'�
New Mau..e _ z Addition EJ Replacement Windows Arleration(s) E ° Roalinr r,
or Doors }
:accessory Bldg. � 4 Dernolitior:i�€ New Signs Decks. � Siding ` Other I Nm
Ia g
Y `�(} }`f'�i ts�? il,.r� .lr•t S'�.�`Ct""` �F."s 3,�E^ 3
6s. if New house and or addition to existing housing, COMDlete the following-,
(v
a
`.• E"��yl't�.pµF ww� Id _. ,'t '',7 r:d'.:�1 `.�I 'f.'f i.,t"'tl� °Y,! .... ,. ..-�sr'C,k� ,
'�.:� � i�.,(,.% ➢ � .',�. ,��„ fC`E �',�p;^', [. 1!.�..;': ,�.?1;.': Q .'il .�f k'S t�tt; '6' _. _. __.,. .�..-....____
i
E x
y a�Fr C r. 04 6s t " ta— _.,.. . ,__......,,_ � 'S� _�N 7C' � _�!@_I" 11 C.' �1[" I #`l�cl �C
rt
case .!@:.°'r� vM�' _...._.�.�.. N';' {. 'r_;l1°tSIE':1>e`':W11
d
a. .., a.
tC ..__.,. _ __.._....___.,.,_...__._........._..,_.._.
f ,
i
I,tIt At,?
'"fc
I
SECTION 7a - OWNER AUTHORIZATION .TO BE COMPLETED WHE14
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_ t1
1n d �� Et tw=t �'et, t ..ar, .,
Nelson Shifflett, Valley Home Improvement, _ Inc . �....1 .r6
m L,r
��P�c:�,�:►re¢a> Ls ,��, -,ate I
i
r
N.els�n �rft�ks V�l .ey Hama mgr �ment,_ Inf"
`IC b%- dccurc try
Nelson Shi f fle t.t*..__ _
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
azkin
#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
City of Northampton Status of Pi6fiit;
Building Department Curb Cut/Dveway Permit
212 Main Street Sewer/Septic Availability .
Room 100 W tier/Well Availability
!Northampton, MA 01060 Two°Sets oftructurai Plans
DEC l 8 ' W hone 413-587.1240 Fax 413-587-1272 Plot/Site
t.._
Pther Specifyy
APPLICATION40 CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property.Address: This section to be completed by office
Map Lot _Unit
Zone Overlay District
Elm St.District__,_ CS District _
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Marne(Print) __�, Current Mailing Ad s s:
_ Telephone c 7 lU
Signa
2. Authorized Agent: elson Shif f Lett
alley Home Improvement Inc. P.O. Box 60_627, Florence, N!A 01062
ame P nt) Current Mailing Address:
IZV61-al 584-7522
Signature Telephone
i SECTION 3 - ESTIMATED CONSTRUCTION COST
Item Estimated Cost(Doilars) to be Offl iu! Usc Orf
completed bypermit applicant
1. Building 7 �� (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of i
Construction from 6 I
3. Plumbing Building Permit Fee
i
4, Mechanical (HVAC)
5. :-ire Protection
6. Total = (l +2 + 3 +4 + 5) /,5-&0 Check Number U d L
This Section For Official Use Only
Building Permit Number: Date Issued:
l
Signature:
Building Commissioner/Inspector of Buildings Date _
File#BP-2014-0738
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 922 RYAN RD
MAP 35 PARCEL 060 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REMODEL BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
Demoliti elay
Sign of Buil i cial 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.
922 RYAN RD BP-2014-0738
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -060 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0738
Project# JS-2014-001252
Est.Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 50616.72 Owner: ADELMAN KAREN D&MARY CURTIN
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 922 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.1211812013 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATHROOM
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 12/18/2013 0:00:00 $90.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner