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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 060300
Birthdate: 09/22/1950
1 Expires: 09/2212008 Tr.no: 1182.0
^ Restricted: 1 G
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627 G,
- FLORENCE, MA 01062 /J
Commissioner
� �� ✓� 7 �cr X �c..�Bo�r�lne ula_iOns an tanAs
One Ashburton Place - Room 1301
Boston. Massachusetts 02) 108
Home Improvement Contractor Recristration
Reqistration: 105543
Type: Private Corporation
Expiration: 7/17/2008
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
DPS-CAI 0 SOM-04/05-PC8698
Board of Building Regulati 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: 7/1712008 Boston,Ma.02108
Type: Private Corporation
VALLEY HOME IMPROVEMENT INC.
Neison Shifflett
340 Riverside0r. �..�0-A�� -- ---- --— — ---
Northampton, MA 01060 Deputy Administrator Not without signature
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DEPARTMENT OF BUILDINTG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION LNSUR.A_NCE AFFIDAVIT
I, Nelson Shifflett - Valley Home Improvement Inc .
{li�nserJpt�ralittee}
with a principal place of business/residence at:
340 Riverside Drive, Northampton, MA 01060 (phoncJ.') 584-7522
do hereby certify, under the pains and penalties of pet' th.._:
( I am an employe. providing the iollo'vir_s,worker's cotn:)ensaLon coverage For -my
employees working on tilis job:
A. I .M. Mutual Ins. Co. WMZ8005610 01 200_7_ 2/1/08
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(Incu ce Company) (Pclicy Number) _ (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (ci.cie one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expirano a Date)
(Name of Contractor) Uns rancc Comuairy/Po?cv Number; (:xDirt:noa Date)
(Name of Connector) (Insurance: Company;Poiiccy (Expirmion Date)
(Name of Contractor) (Insurance Comraany/Policy Number) (Expiration Date)
(attach additional sxct ifnocessary to iac}ude i farmation pectaiuing to ail« actor's)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who caploy peso[,to do�*aint_ e=__.� o=str aloe or repair work oc a dwelling of
not moe,s than throe units in which the homeowner raids or on the groua6 appuuten thmcw arc not generally oo=daed to be
employers under the worker's compcmaiioa Act(GL152-s 1(5)�application by a homeowner for a license cc pant may evidence the
legal ctahus of an employer under the Work oes Compemation Ace_
I understand that a copy of thin ctatemact tray be forwrxdod to the Dtpartmoo[of IndU risl Aca Offtoc of Innuaow for the
coverage vai&caiioa and that fail=to saute covr_T g tinder section 25A of MGL 152 can lead to the imposition of mminsl penalties
mixing of a fine of up to S1,500.00 and/or impi iso�of up to one year and civil pmaltics in the form of a Stop Work order and a
find of 5100.00 a day against mc.
Signed this ____day of 14.1 For dcpatarutal use only
Permit Number
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shifflett 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, Northampton, MA 0706n 9/22/08
Address Expiration Date
584-7522
Signature Telephone
0--J#&N�
9. Registered Hge Improvement Contractors . 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 submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... X No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"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-year 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
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Brief Description of Proposed Work: em.9 de, .rXiJ��G U 1- RC e'*-j&,jvr c,�G�1r� - /,�✓� u�ti.]e�.►w!
Alteration of existing bedroom Yes No Adding new bedroom Yes 4---No
Attached Narrative _ Renovating unfinished basement Yes t--"'No �
P!ans Attached Roll _ Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family_ TNo Family Other
b. Number of rooms in each family unit: Number of Bathrooms i
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Is there a garage attached?
Proposed So;uare footage of new cor,struc: cn. /� _ Dimensions
i
e ;Number :l s:c.r!es?
I n�1
Method of heating' /'i7 _ irepiaces or Wcodstoves I; amber of each I
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g. Energy Corservat:on Compliance. ftascheck Energy Compliance form attached?
ype cf construction
i. Is construction within 100 ft. of wetlands? Yes No Is -orst,,ucticn wi:hin 100 yr. floccclain Yes No
j
i. Depth of basement or cellar floor below fi.-shed grade
k. Will building conform to the Building and Zoning regulations? des No -
Septic Tank City Sewer ✓� Private well City water Suopiy
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SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,
J� A�►,.11.r de e, t as Cwner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement Inc to act on
my half. in al matters relative to work authorized by this building permit application.
Signature of Ownetv 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.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print NameM
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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 \ 7 ��
Building Height r
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
arkina)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO — � Z 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:
f,
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway PR. t
212 Main Street Sewer/Septic,Availability .
Room 100 Water/Well Availability
Northampton, MA 01060 Two`Sets of structural Plans
phone 413=587.1240 Fax 413.587.1272 Plot/Site RAI x
Other Specify �r� �
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:
/A/- Map Lot Unit
f �� Zone Overlay District
NO I" i
Elm St. District CB District _
i SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2_1 Owner of Record:
;I
Cu rer• U1 n 'cdres
^lamz!Print; � L�
Te'ephone
Signature
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2.2 Authorized Agent: Nelson shif f Lett
_Valley Home Improvement Inc. P.O. Box 60627, Florence, MA 01062
Name(Pri t Current Mailing Address:
� 584-7522
Signature Teiephone-T-SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official use Oriy
completed by permit applicant
i
_. Building (a) Building Permit Fee i
2. Electrical (b) Estimated Total Cost of
J�D Construction from 6
3. Plumbing Building Permit Fee
Poo 4. Mechanical (HVAC)
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5. Fire Protection
6. Total = /, + 2 + 3 + 4 + 5) . .3So Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
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Signature:
Building Commissioner/Inspector of Buildings Date
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File#BP-2007-0835
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 13 BAYBERRY LANE
MAP 35 PARCEL 236 001 ZONE SR
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: REMODEL BATH&RECONFIGURE BEDROOM&ADD WINDOW
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INY,QRMATION 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 C ssion
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.
BP-2007-0835
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-2007-0835
Project# JS-2007-001374
Est. Cost: $35000.00
Fee: $175.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Valley Home Improvement, Inc 060300
Lot Size(sq.ft.): 40946.40 Owner: BOWLES GEORGE&SHAYNE BEEDE
Zoning: SR Applicant: Valley Home Improvement, Inc
AT. 13 BAYBERRY LANE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:31712007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATH & RECONFIGURE BEDROOM
& ADD WINDOW
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 Occupant signature:
FeeType: Date Paid: Amount:
Building 3/7/2007 0:00:00 $175.002226
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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