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9=o C o 'Warfilaili Jtell
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m DEPARTMENT OF BUILDDIC INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Nelson A. Shifflett / Valley Home Improvement, Inc
(liceu permittce)
with a principal place of business/residence at:
320 Riverside Drive Northampton, MA 01060 (phone#) (413) 584-752.2
(strr_t/ci ty/statLl�p)
do hereby certify, under the pains and penalties of perjury, that:
M I am an employer providing the following workers compensation coverage for my
employees working on this job:
Travelers Insurance Co. U13888D9983 2/1/00
mince 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) (Insurancc Company/Policy Number) (Expimbon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insutance Company/Policy Number) (Expiration Date)
(artach additioml siwet if noo=ury to inchxk information pertaining to all coats )
( ) I am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whiles homeowners who employ praons to do rmmrr„ coast<vction or repair work on a dwelling of
not mote than throe units is which the bomeowner resides or m the grounds appurtenant ibwdo arc not CCOaally aoasidertd to be
employes under the worker's oor gcas4on Act(GLl52,ss 1(5)),application by a homeow=far a license or permit may evidmm tbo
legal statue of an employer uoder the Worker',Compemstion Au.
I uadesstand that a copy of thin eritemem may be forwarded to tbo Deputneo,of Indsutrial Aecideaiif office of Insurance for the
coverage VMficaiioo and that fadW a to Surat covaago under soctim 25A of MGL 152 an lad to the impos oa of criminal penalties
oomistiag of a fine of up to S 1,500.00 andlor impriso of up to one ytar and civil penahia in the form of a Stop Work Orda and a
firm o(5100.00 a day against me.
Signed this_Z`day of f 1999 Far dcpartmootsl ale
Permit Number
Map# Lot#
Signahtrc of Li erun
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. 7 � Alterations
NORTHAMPTON, MASS. � - � 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
a
Garage
1. Location ! `.Ocf�� vac Lot No.
2. Owner's name / 1� /U �-'��� t!�O dl. Z-V/AJ Address 3. Builder'sname ' Address Z)
Mass.Construction Supervisor's License No. C� 6�cJ6 Expiration Date
4. Addition
5. Alteration iy;j h e r
6. New Porch Ay y f e�, A
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost:- J
J
The undersigned certifies that the above statemcnts are we to the best of his, t
knowledge and belief.
Signature of responsible app leant
�F A L J 1
Remarks i�S l t' ��v f tJ>k r h 9 W h•� ,[ C11 // ,6+-e- 071 A m
12 �; �/ wvLl NO &j t1WC5 CA /emu
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1& Do any signs exist on the property? YES NO
IF YES, describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YE_S NO
IF YES,describe size,type and location:
11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This column to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: 02 R: L: R:
- rear --
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
bpaved parkzngf
# of -Parking Spaces
# (of Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
DATE: .1d, 7' 91 APPLICANT's SIGNATURE v
NOTE: Issuance of a zoning permit does not relieve an "Pplioaffs burden to comply with an
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Public Works and other applicable permit granting authorities.
FILE #
• ' ` '`� � U
6;
I , DEC g
L r�
File Nov �/`a G2 J .
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
0/06 Z--
Address:-?Z6 elephone: `7� z
2. Owner of Property:
Address:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): •�c�-S/ ���/�/ ��� ���/ �
4. Job Location:
Parcel Id: Zoning Map#_-- 4 _ Parcel# District(s):_ �!
(TO BE FILLED IN BY THE OUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
%O j�l XJ 1"C9 �J / J�J din �,�a Sk1 /boa f
7. Attached Plans: ✓ Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special Permit/Vadance/Finding ever been issued for/on the site?
NO 6/' 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#
9. 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:
(FORM CONTINUES ON OTHER SIDE)
W,0(4
File#BP-2000-0583
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 (413)584-7522
PROPERTY LOCATION 47 GOLDEN DR
MAP 29 PARCEL 423 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 FINISH BASEMENT ENTRY/MUDROOM&INSTALL ROOF OVER ENTRY DOOR
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 FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved 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 mmission
/Z
ln-19,9
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.
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47 GOLDEN DR BP-2000-0583
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-423 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-0583
Project# JS-2000-1047
Est.Cost:$7500.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq.ft.): 14374.80 Owner: GOODWIN STEVEN D&GAY L
Zoning:URA Applicant: Valley Home Improvement, Inc
A'l: 47 GOLDEN DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers Compensation
FLORENCE 01062 ISSUED ON.12115199 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH BASEMENT ENTRY/MUDROOM &
INSTALL ROOF OVER ENTRY DOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings;
Rough: Rough,;//4,r-2j/7 House# Foundation:
Final. Final:
Rough Frame: dk ;?- /ea& AvL
Gas Fire Department Fireplace/Chimney:
Rough: L' Insulation;
Final: Smoke: Final: %I-0-0
THIS PERMIT MAY BE REVOKED BY THE CITY NORTHAMPTON UPON VIO TION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee Tyne: Receint No: Date Paid: Check No: Amount:
Building 12/15/99 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
onow