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-- The Commonwealth of,41assachusetts
-T- Department of Industrial Accidents
8fCe of1OYeS192zfV lS
660 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
(A�lg icantmdrmatian'' `` `". '� a EMMUZU MEW
name:
ra
Incation:
ciry nhnn-,
* i am a homeowner performing all work myself.
* I am a sole proprietor and have no one working in any capacity
GQ I am an ernpioyer providing workers' compensation for my employees working on this job. „
company name: Valley Home Improvement, Inc .
address: 340 Riverside Drive -
city: Northampton. Hi;_ 01050 nhone-1: 413-584-7522
insurancecn. ??cad-a Insurance Co. oalicv=` WCA 0109302-:-2.
I am a sole proprietor, general contractor. or homeowner(circle one) and have hired the contractors listed below who have
the -ollowina workers' compensation ooiicas:
company name:
address:
cit-V: r3hone=:
insurance co. _policy
company name:
address-
cirv• phone :
insurance co nolicv 4
c additroas s t'eetif news- sa•'�"^�-''' - -
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand that a
copy of this statement may he forwarded to cite Office of Investizations of the DIA for coveragc verification.
1 do herebt:certify under the pains and penalties of perjure that the information provided above is true and correct.
I — /
Signature L'- Date
Print name /`��L r� Phone
t'official use only do t N e i this area to be completed by city or town official
tom:
city or town: permitAicense r'IBuilding Department
OLicetuing Board
O check if immediate response is required O
selectmen's Once
OHealth Department
contact person: phone 9; 00ther
(,-,-d;,-V NA)
ite L`c e e/ie6,eez-wI!l c` cccite�.;;!
✓ BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
.� Number: CS 060300
,.� Birthdate: 09/2211950
l Expires: 09/22/2008 Tr. no: 1182.0
Restricted: 1 G
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062
Commissioner
-er
_:- Board or Building egula�ns and tandarcis
One Ashburton Place - Room 1301
Boston. Iassachuseas 02108
Home Improvement Contractor Registration
Repistraticn: 1 C
Type. a.e _crrorar.c^
cxoiraticn _. ?
V,=.LLEY HOME IMPROVEMENT INC.
Ne,son Snif sett — - - ---
P.O. Box 60627 --- - -
FLORENCE, Nip; 01062 ------ — -
Update address and return card. Ntark r eason for chanZe.
Address — Rene«ai — Emoiovment Lost Card
e
..a ii?a Y.»vind/u/�¢Cl1L :�,,��Q,:,;✓lCitc4:dlw
Board of Buildin,Regulations and Standards License or registration valid for individui use )ni%
rCME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 1G5543 Board of Buiidin- Re-ulations and standards
�'- One Ashburton Place Rm 1301
Expiration: 7/1 7'2^C8 Boston.Ma. 02108
Type: Private Corceration
"CME ,1PF.CVE—MEN-
\Ielson S'm"!e`..
;u0
cr.^amc;gin. ... ,, Depury.administrator
�otd withoutsi_nature
T�
.-r.
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shifflet.t 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive Northam tern, MA n1n9n 9/22/08
Address Expiration Date
584-7522 f
Signature Telephone i
9 Rediteriff Home Improvement Contractor:.:. _ Not Applicable ❑
Valley Home Improvemment, Inc 105543
Company Name Registration Number
340 Riverside Drive 7/17/08
Address Expiration Date
Northampton, MA 01060 Telephom- 584-7522
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFI:%AVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation insurance affidavit : ust be completed nd submitted with this application. Failure.o provide this affidavit
will result in the denial of the issuance of the -.uiiding permit.
a
Signed Affidavit Attached Yes....... X No...... ❑
11. - Nome Owner Exemption
The current exemption for"homeowners"was extender to include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individual :..r hire who does not possess a license, provided that the owner acts
as supervisor. C14R 730 Sixth Edition Section 10-:.3.5.1.
Definition of Homeowner: Person(s)who own a part-i 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,a --ached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one f)me in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Officio:.,on a form acceptable to the Building Official.that he/she shall be
responsible for all such work performed under the 1-gilding 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
T,
t'
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ I Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] /J Other j�(f
Brief Description of Proposed Work:
Alteration of existing bedroom Yes__Z`No Adding new bedroom Yes No
Attached Narrative _ Renovating unfinished basement Yes No
Plans Attached Roll _ Sheet
6a. If New house and or addition to existing housin& complete the following:
a. Use of building : One Family_ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
i
I Is there a garage attached? A
G
�o�
d. Proposed Square footage of new conscruc:icn. ���i f.� Dimensions j
i
i
e. Number cf stcries?
I
f. Method cf heat;ng? Firepiaces or Woodstoves Number of each
I
i
i g. Energy Conservation Compliance. Mascheck Energ< Compliance for attacred?
I �
-ype cf ccnstruction
i. is construc:icn within 100 ft. of wetlands? Yes _�No. is construction within 'OO yr. flccdpiain Yes No
i
j. Depth of 'casement or cellar floor below finished grade
k. 'Hill building conform to the Building and Zoning regulations? (es 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
7o L' as Owner of the subject property
hereby authcrize Nelson Shif f lett, Valley Home Improvement Inc to act on
my half, in all matters re at ve to work authorized by this building permit application.
Signa e of Owner Date
r
I, Nelson Shif flett, Valley Home Imnrnyp nsant nc_ 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
W 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
y '
Setbacks Front
Side L: R: t✓ L: R:
Rear to
Building Height 1
Bldg. Square Footage ` (} %
Open Space Footage I %
(Lot area minus bldg&paved
arkine)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Sp cial 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 y 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:
:x�epgrtment use only
City of Northampton StatusofPeG+nit<
Building Department Curb Cut/Dr+vewa
sr
212 Main Street Sewer/Septic Ava+Cab+i r 1 -4
Room 100 Water/Well Ava+lab+hty of _
Northampton, MA 01060 Twa Sets of,S ' ral;Ptans
t t4�a
phone 413 587.1240 Fax 413-587-1272 !?iot/Site Pt CZ f Di Y
Other Specie
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
&4hA1_r Map Lot Unit
(lry Zone Overlay District
I
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam (Prim) Current Madi i�adre5�j
Teiephone
Sigr lure
2.2 Authorized Agent: Nelson Shzfflett
Valley Rome Improvement, Inc. P .O. Box 60627 , Florence, MA 01062
Name(Print) Current Mailing Address:
584-7522
Signature Teiephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by oerrnit applicant
:. Building (a) Building Permit Fee
2. E!ectrical (b) Estimated Total Cost of
/0 e2vo Construction from 6
3. Plumbing S, Building Permit Fee
i
E
4. Mechanical (HVAC)
S. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) 61 00 Check Number 3
This Section For Official Use Only
Building Permit Number: Date Issued:
`mature:
(( Building Commissioner/Inspector of Buildings Date
File#BP-2007-0735
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413) 584-7522
PROPERTY LOCATION 44 BEATTIE DR
MAP 29 PARCEL 217 001 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
Tpeof Construction: FINISH BASEMENT REC ROOM REMODEL KITCHEN&BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE' FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Co ion
Signature o Building fficial 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.
NOW
a
. . .fir
BP-2007-0735
GIS#: COMMONWEALTH OF MASSACHUSETTS
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-2007-0735
Project# JS-2007-001119
Est.Cost: $50.00
Fee: $250.00 PERMISSION IS HEREBY GRANTED TO:
Const, Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 077279
Lot Size(sa. ft.): 12501.72 Owner: STONE JUDITH A
Zoning: URA Applicant: Valley Home Improvement, Inc
AT. 44 BEATTIE DR
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:112412007 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT REC ROOM, REMODEL
KITCHEN & BATH
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 1/24/2007 0:00:00 $250.0022033
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo