29-439 (2) —
a a 1 fitly of Norrth mptall ,T-)�
DEPA TVENT OF BUILDING INSPECTIONS C
212 _Baia Street ' 'Municipal Building
?Northampton, Bass. 41060 y
WORKER'S CON PENSATION TNtStiR4NCE A , AVU
I, Nelson Shifflett, Valley Home Improvement, _Inc .
(lic.°aseJpezmiti�)
with a principal place of business/residence at:
340 Riverside Dr. , Northampton, MA, 01060 (phone: l 584-7522
do hereby ceYiLry, under the pains and pe=ities of per urv,
(g) I am an employer providing the followI-ing wcrkcrrs compcns-=oo covenige zor my
-alpiovets wortrdng on this job:
Acadia Insurance Co . 0109302 -11 2/1/06
(T-asl=�Compam) (Polk"Number) (Expiradon Date)
( ) i am a sole proprietor, geaerai conts-ac-zor or Lomeov,Ter (crcie one) and have Lire`'
the contractors Listed below who have the follow.ng worker's C�Omoensaaorl policies:
(dame of CoaL~a='-) Znsuranc-c Cotapazy"Potic-r umcc:) Datc)
01 ,.1a=-an c-- IIIDa^�'i i�CIIC Vll> zC�'` :vi u Date,;
�I`a C of ConiruCior) (Lasi c-- Comp—my/PoUc-; Date,
(Name of Coatrac*.or) (InsI== Company/Po&- Nunn u) (Exei-auon Dares)
(aztact ad'&-,'ccnl sheet ifaeoeasry to iaetiude m:or nation pet&=zg to all--oa=*ztc:a)
( ) 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 thst while homco%mm who ctplay pez.^m to do=xb=•.-,ate c==j tioa or repair work an a dwvlling of
nrx mom than three units is wfrch the homoowoe resides or on the grvaa±s zppur-=&nt thGCn are oot garcally oocrdacd:o be
e=ploycs under the workers o=p=satioa Act(GL157-=1(5)),application by a homwwnrs far a 6==a Peaa eery n-3cacc the
legal stahaa of an att--ployer under dw Workees Campomafioa Act
I Lm8c e nd that a oopy of this rt tcmmt mxy bo forwurdod to tba Dcpartr3c�of Indasrisl A=&.,i Offioa of Ia7xx ca for the
coverage verMcation aad that failure to sea.tre covt a under section 25A of MGL 152 can lend to t5c jnxpositioc of mraiatl pecsl>e
coat&dng of a fine of up to S1,500.00 mod/or i aoanrci of up to cne ye r rod civil pemhia in the form of a Stop Work Orel--and a
fm of 5100.00 a day agiina m.
`'
Signed this y day of h ')��3 For dq=tn=3W—mty
Pcrmit Number
Mai)4 Lot n
v
f �
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License_Holder : Nelson Shifflet2t 060300
Valley Home Improvement, Inc . License Number
340 Riverside Drive, Northam on, MA 010-90 9/22/06
Address Expiration Date
584-7522
Signature Telephone
MR
9. Re Istered HoommProvement Contractor: Not Applicable ❑
Valley Home Impv Tnc 105543
Company Name Registration Number
340 Riverside Drive 7/17/06
Address Expiration Date
Northampton, MA 01060 Teeahcr:e 584-7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensa-icn Insurance affidavit must be corn.cleted and submitted with this application. Failure to provice ; is a :idavit i
vMl result in the cenlal of the :ssuarce of the building 2ermit.
Signed Affidavit attached Yes....... X No...... 7
11. - Home Owner Exemption
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(1) or two(--) 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 heishe 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. 1 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 actinz 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 undersi_ned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances. State and Local Zoning Laws and State of lylassachusetts General Laws Annotated.
Homeowner Signature
r �
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemen Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ 1 j
• i
Brief Description of Proposed Work: OIL AC,C 21ebtl VJ DO WS
I
Alteration of existing bedroom Yes -A No Adding new bedroom Yes '� No
Attached Narrative Renovating unfinished basement Yes '� N
Plans Attached Roll _ Sheet F,
6a. If New house and or addition to existing housing complete the following: j
a. Use of building : One Family Two Family Other
o. Number of rooms in each family unit: Number of Bathrooms
... s there a garage attached?
Proposed Sc,uare footage of new construction. Dimens:cns
N Lm-er ct =_tones?
Met-,cd cf hearing? Firepiaces :r `.Vicedstcves PJurber of
5
trorg'y C onser`dat'on Compliance. Mascileck Energy Compliance for,T, ai:acn2d?
-ype of construction
s ccnstructicn within 100 ft. of wetlands? Yes No. Is cons z ruc-;on within '00 yr. ,ccdp a! 'e -
Deoth of basement or cellar floor below finished grade
',. 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
W5m � LL-- as C,.vner of the suc;ect prccer.y l
I i
:ereby authorize Nelson Shifflett, Valley Home Improvement Inc . to act on
my behalf. in all matters relative to work authorized by this building permit application. !
i
Signature kowner Date
I
I, Nelson Shifflett, Valley Home Improvement Tnc as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best cf my
knowledge and belief.
t
Signed under the pains and penalties of pe 'u
Nelson Shifflett
Print Name
4 �
Y
Section 4.
ALL INFORMATION TMUST 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:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
f_
Room 100 Water/Well Availability
Northampton, MA 01060 Trvo Sets of Structural Plans
phone 413-587.1240 Fax 413.587.1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i
SECTION 1 - SITE INFORMATION
j 1.1 Property Address: This section to be completed by office
I
G �G��1 Gil Map Lot Unit
a /�/ Zone Overlay District
G ll� Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: GL//LIB fir
Name(°rnt` l w. c` Current Maifing rcdress:
Te!ecrone,,, � O
2.2 Authorized Agent: Nelson Shifflett
I
I
Valley Home Improvement, Inc. P .O. Box 60627, Florence, MA Q1062
,game(Pint) Current ,Ma ling Acdress:
r✓' 584-7522
Sigrature T eiepnone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Ite^, Estimated Cost(Dcllars)to be Of icial Use Only
completed by permit aoclicant I
i
5u, ding �' (a) Building Permit Fee I
2. Electrical (b) Estimated Total Cost of 7j Oda
Construction from 6
3. Plumbing Building Permit Fee
A. %lec~lanicai (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) s Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
67 ELLINGTON RD BP-2006-0468
GIs#: COMMONWEALTH OF MASSACHUSETTS
M Block:29-439 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0468
Project# JS-2006-0688
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use croup: Valley Home Improvement, Inc 105543
Lot Size(sq. ft.): 10018.80 Owner: FINLEY JAMES A JR&MICHELLE G
Zoning:URA Applicant: Valley Home Improvement, Inc
AT. 67 ELLINGTON RD
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.11 1112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 11/1/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo