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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(license&permittee)
with a principal place of business/residence at:
(phone#)
(str�dcity/� fa"L1DS
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 Conlractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed if ttaxaary to include infannarion pertaining to all 000tr�)
( ) 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 p=ons to do maia �construction or rcpac work on a dwelling of
not mote than time units in which the homeowner resides or on the grounds appurtenant thereto are not soxmity considered to be
employers under the sec's.oration Act(GL152,=1(5)�application try a homeowner for a lime or permit m:sy evid4mcx the
legal states of an employer under the Wonder's Compensation AcL
I understand that a copy of this uatrnxat may be farwardad to the Deparmnmt of Inghutrial Aod&m&Office of Iosumucc for the
coverage verification and that failure to sxure coverage tinder section 25 A of MOL 152 can lead to tha imposition of criminal penalties
000si:z of a&ne of up to$1.500.00 and/or imprisoamcni of up to am year and civil penalties in the form of a Stop Work order sod a
five of 5100.00 a day against me.
Ig dy O ! For depctaraa use only
Permit Number
0 / ' y� . Maps Lot#
i
'gnature of Li erini6e
' {`E�?d�6rLts:tses7:.�aqaCi"1Ism'
FA-060300
NELSON A Sff1FFLETT , �
PO BOX 60627
FLORENCE MA~(3lt3ts2 ;, ,
arra� sa:ae 0912212€314
IC
Office of Consumer Affairs and Business Regulation
10 lark Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration; 105543
Type: Private Corporation
Expiration: 713712014 Tr# 22 6093
VALLEY HOME IMPROVEMENT INC,
Nelsen Shifflett
P.O. Box 60627
FLORENCE, MA 01062
Update;Address and return card. Mirk reason for eb ange.
Addr"s Renewal Employment Lost Car€l
.,>
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Nang-of License Holder: Nel,son Shif f le.tt _ 060300
Valley Home Improvement, Inc. License Number
340 Riverside ,rive, North amp on., MA 010,60 9/22
— i
Address I Expiration Date
� 584-7522
Signature Telephone —
i
9 Redstered Nome improvement Contractor: Not Applicable 0
Vall 105543
Compaq Name Registration Number
340 Riverside Drive ___ ____ �:0 1's� _._._
Address Expiration Date
Northampton, MA 01060 Telephone-5 8 4-7 5 2 2
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....... 0 No...... 0
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.CVIR 780 Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which lie/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. n 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 l5; (Liability of) tnployers 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 tinder this permit.
The undersigned"homeowner",certifies and assumes responsibility for compliance with tllz`Mate Building Code,Ci}'of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _._---_-._ - - ---- --
£, Til N S. DESCRIPTION OF PROPOSED WORK (check All�:pp
Nvw Hcu-.t: _ Addition L � Replacement Windows A:teraticsn(s)[7 Raotinl;
Or Doom
,accessory Bldg. 2 Demolition:) New Signs j Decks Siding I Other !i
€t_ F,r ;piafie_c�F►L lxaf1lU!�c In's
(o Mel tv 641 crjuA sf,ce �f p r in3.u&h PA-,0O Ii.lfls e)/Cei�,s�j air . 1 ✓ei..#4i.,2ri z
r,. Y x 'r�l�' Clr .tr f t �:pZi Yr4 V� i i ? te�f. 1FrE ✓(` lw. "16
f
�n I .. �t,d !p.It�t.
6b. if New house and or addition to existing. housing. COMMete the following:
'l "n't;
ul •kt til�..,a�
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` G' � "E r .,RG'"'S_.4"4.aiPC,,. 4.�"ke"i! Is7-:�^a ECE?"'Uy 1.,.`Tt:.°I`.Fli�_ (�r'T', r:'.tL I'BC:.`
vrCRtll 10"I 't �!t�r uk ;:,pc;5? ':'�:S d�. i, G::It�EStt;�.a�,�,t1 ��.. n�t. i OG°°;r. °3_,.,.:a,pl�::t ---------
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SECTION 7a • OVYNER AUTHORIZATION •TO 13E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Nelson Shifflett, _Valley_ Home Improvement,_..Inc
S"T Ko Vn 3'„', 1tit [,..6
_i4G�Qn gl�i__f1QL�,. y�lie� .L47./ftRG r?1e]f.T��c�a� �_,r �.�':, Irlilt FiF�• 3 .'4!"�':? )
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
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
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 Permit
j' 18 Building Department Curb Cut/Driveway Permit
DEC ���3 -� 12 Main Street Sewer/Septic`Availability
i Room 100 Water/WeII AVaiIability
IpO-iampton, MA 01060 Two Sets of Structural Plans
�— — -- phoneA13=5 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
MT
APPLICATION TO 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
3 1 -DY-P-W6P-n Map Lot Unit
{—i Qt`e¢" ce f1-40a of c*j( Zone Overlay District
Elm St.District CB District
SECTION'2'-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jashu(x- 31 Drews-en 1)r:- Fiareive /Q4 ofoy,,,a
Name( int) Current Mailing Address:
yi 3 - .19-H-4—14113
Telephone
S' n ure
2.2 Authorized Agent:
e
Nlson Shl I A Vk d let, Morn if 5yy 'A"IV ra jde- Pr: �-l6r�C ,pia-oicZ,
Name(Print) t Current Mailing Address:
4113- . - -75-aD
Signature Telephone
SECTION'3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 5OX`00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from &
3. Plumbing Building Permit Fee
4, Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) ,57C)X. 00 Check Number 6
This Section For Official Use Only
Building Permit Number. Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2014-0736
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 31 DREWSEN DR
MAP 35 PARCEL 121 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC&WALL INSULATION
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
INFORMATION 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
e i D y
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.
31 DREWSEN DR BP-2014-0736
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 121 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-2014-0736
Project# JS-2014-001250
Est.Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sg.ft.): 10497.96 Owner: THIBEDAU KRISTIN M&JOSHUA P
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 31 DREWSEN DR
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.-INSTALL ATTIC & WALL 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 12/18/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner