29-424 9�0 O afl Crzf of Naztljamptutt
� B �aaartcflttsrtta
m DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMTENSATION RiSURANCE AFFIDAVIT
I, Nelson Shifflett, Valley Home Improvement, Inc.
(lictrnscclpermittee}
vnth a principal place of business/residence at:
340 Riverside Dr. , Northampton,MA 01060 (phoney,) 584-7522
do hereby certify, under the pains and penalties of perjury, that:
(4 I am an employer providing the following wor'ker's compensation coverage for my
employees worming on this job:
Acadia Insurance Co. 01. 09302-10 2/1/05
(Insurance Company) (Polio Number) (E.==tfbn Daze)
( ) i am a sole proprietor, general contractor or homeowner (cycle one) and have hued
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 Nuinber) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Nutnhex) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(arrac-+r additioml shect ifnoomary to include inf�oa pertaining to all eoam aorz)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcsse be aware that wbilo homeowners who cmploy pa-w=to do maintcna cousmie don or rcpait work on a dwelling of
not mom than throe units in which the hotnoowner raids or on the g ound3 zppurtznu thescto arc not goxmily ooatidetcd to be
employ=under the work es c=pens.ation Act(GL152,ss 1(5)�application by a homeowner for a license a permit may evidence the
legal sistus of an employer under the Workers Compensation Act
I understand tbst a oopy of this statement may be forwordod to the Departmcn2 of Lxkurrial Accidw&Offioe of Icairanoe for the
ooveratge verification and that failure to aware ooverago under suction 25A of MOL 132 can lead to the imposition of criminal prnalties
consisting of a fine of up to$1,300.00 sayer im�ct of tip to one year and civil pcotwes is the fans of a Stop Work Order and a
find of 5100.00 a day against tae.
Signed this _da of ICC h 0 V For -1r
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :—Nelson Shif fle t 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drives, Northampton, NA OlnRn 9/22/04
Address Expiration Date
584-7522
Signature Telephone
A Registered Home Improvement Contractor 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....... X No...... ❑
11. - Home Owner Exemption
The current exemption for"homeow-ricrs"was extended to include Owner-occupied Dwellings of one(1) or two(3)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-near 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 15; (Liability of Fmplovers 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
R
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other( ]
Brief Description of Proposed Work: e A
Alteration of existing bedroom Yes !/No Adding new bedroom Yes
Attached Narrative a Renovating unfinished basement Yes l/_ No
Plans Attached Roll - Sheet❑
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?
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
as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement, Inc to act on
my behalf, in all matters r lative to work authorized by this building permit application.
f�411" a, i ____ 21 4 1 4
(K L4Z�
®y
Signat re o V c r_ / ate
I, Nelson Shifflett, Valley Home Improvement mac- 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
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:� J
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 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:
.. a at,use only
,D P rtmen
City of Northampton Status of .,,,e r a= }
Building Department Curb Cut/Drlveway Permit
212 Main Street Sewe"r%Septic Avatta �
Room 100 W /Well Avaabthty � v �
Northampton, MA 01060 T o etsofStural
phone 413-587.1240 Fax 413-587.1272 Plot/Site Pt -"'-
;r r M ,-
Other Speci
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH`A N 0 T I
JUN - 7 2004 Lj
SECTION 1 -SITE INFORMATION
This secllion to d
1.1 Property Address:
ce){ \f ll/f Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C�191CAG /N
Name(Print)// Current y1 ailing Addr s
Telephone
Signature C
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement Inc. P.O. Box 60627, Florence, MA 01062
Name(Prin Current Mailing Address:
tf� 584-7522
Signatu e j Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
Building 5 (a) Building Permit Fee
2. Electrical v(N (b) Estimated Total Cost of
Constructicn from (6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
w is ,,..
55 GOLDEN DR BP-2004-1242
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-424 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2004-1242
Project# JS-2004-1884
Est.Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sa. ft.): 20908.80 Owner: CALLAGHAN KATHERINE L&
Zoning:URA Applicant: Valley Home Improvement, Inc
AT. 55 GOLDEN DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:617104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 6/7/04 0:00:00 18198 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo