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29-424 (2) r FF D w F- D �1\ Fes_- w •� U) a_ \ C) Q U mw LuLL LL w z 0\ r� o , I Ew- \, / O C/) I �/�/ i O � I p cn Q t p w0 Q Zo w ` } U L Le z I ' Q lii z F- 0 i U 1 ocz(D O w u. / w i U / Z II ® w } I z H lf�= Q ° Ld- � J w U) O 2 \ 0 Q w w U U- 0 L) \� z U) O WaO p uj QUw Y) 0 :) O w0 Li W Nl1I �- w (D CL U m w IxO LL 2 U- w z 0 I 1N\ , ui og� / w uj Lli z ~O - I I U) m Q =0 i CL U I Q Q 1 , 1 z -0- 0 II U LL / LL, II ® � I Cl J Z � I I. n Q W Ca O 0 = C U- w000 \0 zIx0 wwo w � QUw � O w0 �'CN/�MPT Of NDZ#Ijalllptalt 9 +� �assacfinsrtta 4 m DEPARTMENT OF BUILDI-NG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT Nelson A. Shifflett / Valley Home Improvement, Inc (llcenswjpernuuee) with a principal place of business/residence at: 320 Riverside Drive. Northampton, MA 01 060 (phone#) (413) 584-7522 (str-.,tici ty/sW&z1 p) do hereby certify, under the pains and penalties of perjury, that: n I am an employer providing the following worker's compensation coverage for my employees working on this iob: Travelers Insurance Co. U3888139983 2/1/01 (Insurance Company) (Policy Number)'' (Expiration Date) O 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 addi6ocal shod ifnooesuy to include information pataining to an ooatm ors) ( ) 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 persons to do m i r ____M_�,oongnw6on or repair work on a dwelling of not more than throe units is which the lwmeowocr resides or ou the 9oun ds appudenan,therdD an not gwetally oomiderod to be employes under the wotlux'a ootnpeusation Act(GL152,sa 1(5)},application by a homeowner for a liccnx or permit may evidence the legal stntua of an employer under the Workers C.ompomation Act I undersund that a copy of thin datemczd may be forwarded to the Depnrtmm2 ofL hx, ial Aaa4=&Office of Inauznoa for the coverage verification and that failure to aeaut coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties 00—Aiag of a fine of up to S1,500.00 and/or imprisonment of up to one ytar and civil pem cs in the form of a Stop Work Order and a f rw of S 100.00 a day against tee. Signed this _day of 2000 Fordgmtmeda —Only Permit Number • r��v�, Map# Lot# Signature of Li etm.i ~ �� * .1 Licensed Construction Supervisor.- Not Applicable 0 Narrieftf License Holder License Number Address Expiration Date Signature Telephone e Not Applicable 0 Company Name Registration Number j ;7,�� 111117Y Address Expiration Dite Telephone 7-5 Z-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. \ on 2W T The current exemption for^komco*nurs'was extended»oinclude Dwellings f one(l) or mx(2)bunUieo 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. Such"homeowner"xhu|! submit tuthe Building Official, on u form acceptable totile Building Official, responsible for all such work performed under the building permit. As,ac6ng your prmcnccon the job site x/i||hc required �omdmc/o time,during and upon comp|odono[the work for which this permit isissued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter )53 (Liability o[Employers to Employees for injuries not resulting in Death)o[the Massachusetts General Laws Annotated,you may be liable torpccaoo(x) 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 Lou \ n and State of Massachusetts General Laws Annotated. Homeowner Signature ' 'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) r'�►`Gy G�-Z� New House ❑ Addition ❑ Replacement Windows Alteration(s)'K Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[d] /C Othh�er [ ] Brief Description of Proposed Work: - /990 iKn�'/G ri J yn Qelw,,ld S Alteration of existing bedroom Yes_JZNo Adding new bedroom Yes y No Attached Narrative 0 Renovating unfinishe basement Yes No Plans Attached Roll ❑ . Sheet C0� L%;el'5 'A,U; 4 `�zza 4,1� f J 6a.1f-Newhous and°or'additi n'to xMi ng housing, com leteAhe`followin : 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. /f)Ze Dimensions e. Number of stories? f. Method of heating? / ter/`/ Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance._ i 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/�f�SG'� -S �/ l�T'. �� f� 'Al G to act on my behalf, in all matters relative to work au horize d by this uilding permit application. Signature of Ow Date f4 s`fJ,o(7-�' 0"r C— 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. Print Name Signature of Owner/Ag Date 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 i Lot Size Frontage IN Setbacks Front Side L: R: L: R: Rear Building Height i Bldg. Square Footage % Open Space Footage % P (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 f� 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? N0 �-f 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: i f Northampton StatusoflP B k� i ng Department Curb%Cut/DrfVe StiPeCrrll 7 Main Street Sewer/Septet lablity' .. oom 100 WterlW 11 DEPT OF_f�'QRtH� } IN P tha pton MA 01060 ,CDING ` is8 •1240 Fax 413-587.1272 Plat/Site P1a �. � 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 ��' Map OY Lot Unit Zone._ Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: /tea ell E /l"lfi GfD(� Telephone 7 Signature 2.2 Authorized Agent: IC�Z S altl _z/ cc�1l /�d 8 l U� Z /�O/�'�f1 �, Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Sv, Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) V Check Number v This Section For Official Use Only Building Permit Number: A on Ign Date Issued: Signature: Building Commissioner/Inspector of Buildings Date r File#BP-2000-1185 APPLICANT/CONTACT PERSON Valley Home Improvement, Inc ADDRESS/PHONE P O Box 60627 (413)584-7522 PROPERTY LOCATION 55 GOLDEN DR MAP 29 PARCEL 424 ZONE URA 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: ADD BATH&MODIFY LAUNDRY IN BASEMENT&REBUILD INTERIOR STAIRS 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 F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: pproved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § —w/ZONING BOARD OF APPEALS 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 Commissp* P Permit from CB Architecture Co ittee Signature of Building Officiar 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. elk 3 �"` nVi w l 55(10101314 DR BP-2000-1185 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-424 CITY OF NORTHAMPTON Lot:-001 Permit: Buildb Category:renovation BUILDING PERMIT Permit# BP-2000-1185 Project# JS-2000-2077 Est.Cost:$10000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Gron : Valley Home Improvement, Inc 060300 Lot Size(sq.ft.): 20908.80 Owner: CALLAGAN KITTY&MICHAEL HOLROYDE Zoning URA Applicant: Vailev Home Improvement, Inc AT: 55 GOLDEN DR Anplicant Address: Phone: Insurance: P O Box 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.6128100 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD BATH & MODIFY LAUNDRY IN BASEMENT & REBUILD INTERIOR STAIRS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground:Q 31vb Service: Meter: $, r9t? Footings: Rough 'g��/�pt Rough: e / ! House# Foundation: Final:��/�� Final: ✓ l/�'� Rough Frame: 01c' Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 0 IC THIS PERMIT MAY BE REVOKED BY THE CITY OF RTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. f� Certificate of Occu anc si nature: Fee Type: Receip o: ate Paid: Check No. Amount: Building 6/28/00 0:00:00 12109 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo