23C-048 The Commonwealth of Massachusetts
--- Department of Industrial Accidents
Office of Investigations
" 600 Washington.street
;5 Boston,M4 02111
www rnass.gov/dia
Workers' Compensation Insurance Affidavit: BuDders/Contractors/Electricians/Plumbers
AyLhcant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: �^ /C!P l ml,5
City/State/Zip: /v IM j7r11'10 If,144,* 67l0 6 0 Phone#:Are you an employer?Check the appropriate box: Type of project(required):
1.[4 I am a employer with 15' 4. [] I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. E]Building addition
[No workers'comp,insurance comp.insurance.:
required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c.152,§1(4),and we have no 13.0 Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance,for my employees Below is the policy and job site
informaataon. _
Insurance Company Name:
Policy 4 or Self-ins.Lie.u,+: �:/1 ,�f , )Fa�l) �� E;.'paratzon Date: /�•�7c1�
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
z r•• v_ r__.,__ SS TOP v OPMETIs and a ne
i�ne up to$i,50t�.c�0 and/or ore-year irrprisonmeni,as w:;la as civil perima��es�u,c a�,��ur w Y�P Vv OlZz Y
of up to$27u.66 a day against-dw Violator. me advised-fit a copy of-i7nYC stEkmeat may be lb vvarr d to the Cwt;;,of
Investigations of the DIA for insurance coverage vegcaftion.
T do hereby cP .' .. tx?ler tea.r�aains and asenaalties�_ penury that the information provided above is trace and correct
Signature: ��2y�°iI .! --� / Date: c,�
Phone 4:
0,o1c&use only. Do not write in this area,to be con pleted by city or town official
City or Town: Permit/License#
1.Board ofKeagth 2,Ru lding Department 3.City/Town Clerk, 4.Electrical Emspector 5.Plu—mhflng Lispector f�
fu.Other
B (contact Person: iL)Or,€4 i
'
'
'
SECTION 8 -CONSTRUCTION SERVICES
Name of Licenqt,�LQ[dler : Nelson 060300
License Number
Valley Home Improvement, Inc.
Expiratiwl Date
Ad es
Telephone
p0aue
Registered Home Improvement Contractor. Not Appllcab:e 0
Valley 105543
Company Name Regist-ation Number
340 Riverp
Address Expiration Da-,e
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
'Norke,s Compensation Insurance aff idav't must be compl 0-ted and submitted with th;s application. Failure to provide this affidawt
will result in the denial of the issuance of the building permit.
11. - Home Owner Exemption
7hecUrrent exemption for"���,,Nmers"was extended m include cne(Um ��) families
and to allow such homeowner monQugcun individual for hire who does not possess u |iconc, provided that the owneracts
as supervisor, CYIR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which hcshe resides or intends to reside,on which there
.` — _ __---- - ` ' . _Workers' Compensation) and Chapter 153 (Liability of Employers to
structures. A erson who constructs more than one horne in a two-year period shall not be considered a,howeowner.
Such"homeowner"shall submit to the Building Official.oil a form acceptable to tile Building Official,that he/she sitaii be
responsible for all such work performed under the buildinLy permit.
Asactin-ConstructionSuperviso 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('Emcl '-^fninjmicsmurex bim—, b`Death)oFthe IvIussochusetts General Laws Annoxoed, vou ninv be liable "orposoo(m
you hire W perform work for you under this permit.
Thconducy�2uod^^homcuvmo/'ucuific�ondussumesrrspnosihi|byfhrcum[Jiunccv/khtheS|mz8uildingCodc,[ityu[
Northampton Ordinances. State and Local Zoning Laws and State of N—lassachuserts General Laxvs Annotated.
Homeowner Signature
-CTICN _j I
5l r�CSCMPTION OF PROPOSED A0PKfch(tk Irl
_p
et
M u w H c u!.t: Acditlon Nir,.dcw . A tef_Aiulv(0
0! Coarr,
Accessory Bidg.
D em G I i ti o-,,_7 New Signs Decks Sidirg ,' i Othe!
Y�
b,nse pcLcK_ S Opt?!rm W u Cedulme 1050aft ae 4 -eilukSe-
W* I
ICL b C, 4 'r"--''-_)�
M11 ?0Y til (Jtr+ L",el I (e-I u tvL e 6-4�,eo_44xw_,v t z e-
6�t If New house and or addition to existing housing, complete the following
T; i7 v, ."t :r)(: vi
Pt
SECTICN 7a - OWNER AUTHORIZATION - TO BE COMPLETED MEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Nelson Shi-Mett, Valley Home Improvement, Inc.
Nelson—Shilf le.-t,—Y-all—ey--Home—,Tmpr-oy-emmt.,—Inc-1,
ItAl
Ne!son Shi le t t.--,,
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
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:
-
� �fit'• S,S `slr
ti l Mugs a r4ugPttB
� aE
DEPARTMENT OF BUILDING INSPECTIONS }
212 Main Street • Municipal Building
Northampton, MA 01060
LOUIS H s ROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1st floor
.30 " " " 2nd floor
.20 " %floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with,a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6(K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only -
* City of Northampton Status of Permit:
� 4
Building Department Curb Cut/Driveway.Permit
212 Main Street Sewer/Septic Availability
6 Room 100 Water/Well Availability
1' e Z
hampton, MA 01060 Uo"Sets of Structural Plans
i/ 43 13-587-1240 Fax 413-587-1272 Plot%Site Plans
Ph.
��ectc+ F Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
c-
38 (rrl,l/Ow) :Jft Map Lot _Unit
!CIA 0 10 Zone Overlay District
Elm St.District CB District____
SECTION 2'-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current ailing Address.
3 -ti-53L/
,ti :.{,. 12.%`° Telephone
Si nature
2.2 Authorized Agent:
L)ej s a n S h t 441 C_4 �c t very� ��r. i"���i- n�� ,1�►�� �rat
Name(Print) Current Mailing
7
;�A X4 Ank w Mailiinng Address:�/ �
Signature Telephone
SECTION 3 -ESTIMOED 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
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0912
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 38 WILLOW ST
MAP 23C PARCEL 048 001 ZONE URA(106)/WSP(103)/WP(55)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 90 A=kh
Fee Paid
Typeof Construction: INSULATE ATTIC&BASEMENT
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 F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I RMATION PRESENTED:
!fP191pproved 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 Commission Permit DPW Storm Water Management
eiNvIitin Delay
nature of Buil g f icial 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.
38 WILLOW ST BP-2014-0912
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C-048 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate ory: electrial BUILDING PERMIT
Permit# BP-2014-0912
Project# JS-2014-001439
Est. Cost: $6800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 50094.00 Owner: CROWTHER LUCILLE R
Zoning. URA(106)/WSP(103)/WP(55)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 38 WILLOW ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:212712014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC & BASEMENT
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 2/27/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner