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GOLDEN DRIVE
ENERGY CONSERVATION APPLICATION FORM FOR
LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS
780 CMR Appendix J
Applicant Name: Ale Site Address: 7 6d1y �('
Applicant Address: P O od Al City Town:
Use Group:
/". �_7/064 Date of Application: L- -c�
Applicant Phone: /�� � Applicant Signature:
Compliance Path(check one):
❑ Prescriptive Package(Limited to 1-or 2-family wood frame buildings heated with fossil fuels only)
Package (A through KK from Table J5.2.lb): Heating Degree Days(HDD61)from Table J5.2.1a:
(For items d. through i., fill in all values that apply from Table J5.2.1b:)
a. Gross Wall Area sq.ft f. Wall R-value R-
b. Glazing Area' sq.ft. g. Floor R-value R-
c. Glazing%(l oo x b_a) % h. Basement wall R-
d. Glazing U-value U- i. Slab Perimeter R-
e. Ceiling R-value R- J. Heating AFUE
❑ Component Performance: "Manual Trade-Off" (Limited to wood or metal framed buildings only)
Climate Zone (from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14
Attach Trade-Off Worksheet from Appendix J, [and hvAC Trade-Off Worksheet,if applicable;
❑ -VAScheck Software
Attach Compliance Report and Inspection Checklist printouts
❑ Home Energy Rating System Evaluation
Attach Home Energy Rating Certificate(HERS ratio,score must be 83 or higher)
❑ Systems Analysis OR ❑ Renewable Energy Sources
Attach Mass Registered Architect or Engineer Analysis
ALTERNATIVE FOR ADDITIONS ONLY:
a. Gross Wall+Ceiling Area )0 G sq.ft. b. Glazing Area' `.�1 sq.ft. c. Glazing%(too
❑ ADDITION with Glazing % (c.)up to 40%may use 780 C M Table J1.1.2.3.1 below:
MAXIMUM U-value MINIMUM R-Values
Fenestration' Ceiling' Wall Floor Basement Wall Slab Perimeter.Depth
039' R-37 R-13 R-19 R-10 R-10 4 ft
1 Glazing Area may be either Rough Opening or Unit dimensions.
2 Based on NFRC listing. Applies either to every unit,or to area-weighted average of all units.
3 R-30 ceiling insulation maybe used in place of R-37 it the insulation achieves the full R-value over the entire ceiling area
(i.e.-not compressed over exterior walls,and including any access openings.)
n
❑ "SUNROOM"addition (greater than 40% glazing-to-wall and ceiling gross area 0 �1
Attach "Consumer Information Form"from 780 CNM Appendix B.
Official's Name: Official's Signature:
Application Approved Denied ❑ Date of Approval/Denial:
Aeason(s) for Denial: (provide additional details as needed on back side)
e ✓/e t0ommonu�e¢` o�✓��aaac�ucaea6 'r
*1611111111110111111k BOARD OF BUILDING REGULATIONS
¢r ° License: CONSTRUCTION SUPERVISOR
Number: CS 060300
i .
Birthdate: 09/2211950
Expires: 09/2212008 Tr.no: 1182.0
— Restricted: 1 G
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627 G—
FLORENCE, MA 01062
Commissioner
glz-e Bo��iVne Re ula�ons an tans
- g g
E
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reqistration: 105543
Type: Private Corporation
Expiration: 7117/2008
VALLEY HOME IMPROVEMENT INC. _
Nelson Shifflett
P.O. Box 60627 ---- - -- - ---__ _. .
FLORENCE, MA 01062 — ------- -
Update Address and return card.Mark reason for change.
Address —' Renewal - Employment Lost Card
0PS-CA1 ii SOM-04/05-P�C�8698�
� ,Jfte T�orwNtOOtule¢���L 4�✓�LQ46Q.Ciu�4er�b
Board of Building Re;ulati ns and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 105543 One Ashburton Place Rm 1301
Expiration: 7/17/2008 Boston,Ma.02108
Type: Private Corporation
VALLEY HOME IMPROVEMENT INC.
Nelson Shifflett
340 Riverside0r. --—�---- --— --
Northampton. MA 01060 Deputy Administrator tiot without signature
Y �
�Tt1nMPJ
�0 oy
aseacETnscffs
m DEPARTMENT OF BUILDrl\TG INSPECTIONS
i=
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSATION TESSURANCE AFFIDAVIT
I, Nelson Shifflett - Valley Home Improvement Inc .
(IiccnserJpetmit`�)
with a principal place of business/residence at:
340 Riverside Drive, Northampton, MA 01060 (phone ) 584-7522
do hereby certify, under the pains and penalties of perjury, tlla_:
(xj I an an employer providing the following worker's compensation coverage for my
employees working on this job:
A. I .M. Mutual Ins. Co. WMZ8005610 01 2007 2/1/08
(Insurance Company) (Polite N-.L=ber) (Expiration Date)
( i I an-1 a sole proprietor, general contractor or homeowner (=c:e one) and have hired
the contractors listed below who have the following worker's canpensadon policies:
(Name of Contractor) (Insurancc Company/Policy Numbc:) (Expiration Date)
(Name of Contractor) rjns--u anc Number) (Exp=,noa Date)
(Naiue of Coatlac:cr) (Lasurancz; Cornea;y r olicy Narrl,-- ) (E,,punuon Date)
(dame of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(artach a.dditicaal sboct ifnarssary to Inctuc:e i-SDrmahon pcuLining to nil=U:ra r3)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing alt the work myself.
*TOTE:please be aware that whilo homcovi=who employ pezons to do mxmt_, x Y =tvr ction or repay work on a dwelling of
not mote than three unite in winch the homeowner resides or oar the Vviads appurtasant tbwdo errs not goxmily caaside ed to be
ensploy=under the vmrkets ocmpc=satioa Act(GL152,ss 1(5)),application by a homeowner for a lie=u or permit may evidence the
legal stahca of an employer under the Woriceet Compomation Ad
I underzuad tbxt a copy of this=teman may be forwarded to tbo Dept...,of Industrial A=dm&Offioo of Inarnoee for the
coverage vrxif catioo and that failure to sc urc coverage under section 25A of MGL 152 can lad to the imposition of criminal penalties
consisting of a fine of up to S 1,500 M and/or=ipruonnicrl of uP to one yew and civil penalties in the form of a Stop Work Order and a
fnc of S 100.00 a day
Signed this of J For l—Only,
permit Number
pis* ,
0 •
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shiffle-t-t 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northam on, MA_ 01060 9/22/08 `
Address Expiration Date
584-7522
Signature Telephone i
9. Registered Ho m rovement Contractor: Not Applicable ❑
Valley Home Improvement, Inc- 105543
Company Name Registration Number
340 Riverside Drive 7/17/08
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 submit-ed with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 20 No...... ❑
11. - Home Owner Exemption
The current exemption for"homeow-ners" 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 in a two-vear 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,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 _
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ 1 Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other;7 1
Brief Description of Proposed Work: i1��,5 /r✓r f' �y✓&'!�%V�/��`��� /i��+� /r //tom Vz
I
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes ----N-o
Attached Narrative - Renovating unfinished basement Yes —IN 0
Plans Attached Roll _ Sheet
sa. If New house and or addition to existing housing, complete the following:
j a. Use of building : One Family y Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
is there a garage attached?
d. Proposed Square footage of new construction. �( _ Dimensions
.. `cumber .ail -stories?
1_ I
ethod cf heating' /�/� =irepiaces or'Wcodstoves N- -ber o e cn --
g. Energy Conservation Compliance, Mascheck Energy Compliance form attached?
I
-y pe cf construction
Is construction within 100 ft. of wetlands? Yes -/No. Is corstruc:ion wig hin 100 yr. �'ocdc,air �s
;. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? / Yes No .
Septic Tank City Sewer lJ Private well City water Supply
I
j SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as �-,;finer of tf e sub c` proper,,
i
hereoy authorize Nelson Shifflett, Valley Home Improvement Inc to act on
-n beha f, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, Nelson Shifflett, Valley Home Improvement, Inc_ 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. f
I
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name II
1
,-"."5- ('G c c A SiL/.gC—C�/1
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 / �U�J / O Go
Frontage /00
0
Setbacks Front ✓/ \
Side L: &R: L: l} R: 3 7
Rear (j l ' 24L
Building Height • G
Bldg. Square Footage
Open Space Footage % kb
(Lot area minus bldg&paved � ) i/�
parking) f� p° '�
#of Parkin,Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
L,//—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 I/ 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
I City of Northampton Status of Perin:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvaila Iillity
Room 100 Water/Well Availability XF
Northampton, MA 01060 Two Sets of Structural Plans
phone 4f3-587.1240 Fax 413.587-1272 Plot/Ste Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I
j SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
1d N(� L Zone Overlay District
C.
Elm St. District — CB District_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
!
2_1 Owner of Record:
',lame(Pri Currer- `.1a link;a
-Signature
i
2,2 Authorized Agent: Nelson Shif fl�tt
i
Valle Home Im rovement / P .O. Box 60627, Florence, MA 01062
'Jame!Print) C::rrer` ,:flailing?.cdress:
584-7522 _
Signature
Te.cphcne
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
'tern Estimated Cost (Dollars) to be Official Use Only
completed by permit a olicant
_. Building (a) Building Permit Fee
2. Electrical a �� i> i (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I +-2 + 3 + 4 + 5) Z2 0 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0920
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 47 GOLDEN DR ,I' Q
MAP 29 PARCEL 423 001 ZONE URA!W
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tpeof Construction: CONSTRUCT 12 X 14 DINING RM &6X 12 KITCHEN ADDITION
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 LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INV9RMATION 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 Commissi
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.
7 GOLUEIt BP-2007-0929
CIS#: COMMONWEALTH OF MASSACHUSETTS
its=423 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-2007-0929
Project# JS-2007-001515
Est. Cost: $70000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sg. ft.): 14374.80 Owner: GOODWIN STEVEN D&GAY L
zoning URA Applicant: Valley Home Improvement, Inc
AT: 47 GOLDEN DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:411012007 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 14 DINING RM & 6X 12
KITCHEN ADDITION
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 4/10/2007 0:00:00 $120.0022344
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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