29-143 (5) The Commonwealth of Massachusetts
+h
Department of Industrial Accidents
Office of Investigations
� 'r-! 600 Washington Street
�= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): //ilia I� f .G _1-,!YY1��J f
Address: ��-
City/State/Zip: 611 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.[9 I am a employer with 15' 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
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. ❑Building addition
[No workers' comp.insurance comp.insurance.1
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 must 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
informatdon.
Insurance Company Name:
Policy#or Self-ins.Lic.#: ,', � -`�''?' Expiration Date: 'i
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
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c sins and enadtdes . pe ' ry that the information pravdded above is true and correct
Si ature: �e�
�J' / Z ' Date:
Phone# i
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
a 4
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Nome of License Holder: NelsOn Shif flett 060300
Valley Home Improvement, Inc. License Number
g�22/� i
340 R' er amptan, MA 01.0bD -
1 Address Expiration Date
_ 584-7522
Signature Telephone
9 Reeistered Home Improvement Contractor: Not Appl icab'<e ❑
Valley Home Improvement, Inc _ ._._ 105543
Company Name Re.-istration Number
i 340 Riverside Drive .. —V-1 If
Address Expiration Date
Northampton, MA 01060 Telephone 584-7522
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
0
Workers Compensation Insurance affidavit must be completed and submitted vJth this application. Failure to provide this affidavit i
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... N No...... ❑
11 - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellin<,:s 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. CNIR 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 horneow_ner.
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 lrlassachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit-.
The undersianed"homeowner"certifies and assumes responsibility for compliance with the State Building Code,Cit} of
Northampton Ordinances, State and Local Zoning Lai vs and State of Massachusetts General Laws Annotated.
homeowner Signature
CTiCN 5. DESMP T ION OF PROPOSE ViOP.K"cFst°_K
Nm E{::use l"ti eEifirsn �! j Replzct rent Wirdcw& A.tersfi^srx(s) i"_ Pacr!inE C`
C: b,a€�rs
€ t
Acccssory B dg. Cemclitio- New Signs Decks. 'i S cirg CCE�er
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'.�..t 'C.. ._6`F�t(6. � •I. i{i'. 6„I°,.,r .�Y.eG `°., .._ s,�! i
Po
6z.. If New house and or addition to existing housing. complete the following-
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_
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_ .,LL .Ir..• Er i rl'r ” I t.,°., r ._t r o ? � & i .t€�.tr;sa�t. •n �w • F �t.l. •�r 'i^;,.,,._ .._. � ...__�._ ,._
6 e"•s, - epF
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SEGTICN 7a - OWNER AUT14ORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTCR APPLIES FOR BUILDING PERMIT
..j,rG11J..1 .� I �, „� � `V`t./�� 1 � �p.•.•,�P�.r q..:� .,. ��-.,."- �...•°.-t�.
,Nelson Shiflett, Valley Home Improvement, Inc.
t
t � d
Ne.1s.on lri £1att,, Xalhey—H ome_Img=y-e me nts InC.
�'k• _��: �:r r�° ° . . _ _.slCL`!S#_ r_� ":fl. [.,r,r..r .,E`'�`tC fir" �Ett; k.p'..'�-�:`elE „ ,SL':� ._,flv'=� . ' . _'!t^., .' .-Fe ",a'f'G.6', `,iIC . �;' 9C?`J
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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
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces /U
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 ;
Lj' City of Northampton Status of Permit:
AM - 8 2014 ilding Department Curb Cut/Driveway Permit
12 Main Street Sewer/SepticAv ail abiIity
,-ections Room 100 Wader/Well Availability
Eieot� ! � ` �� ampton, MA 01060 Twis'Sets,of.St6icturai Plans
r
phone 413-587.1240 Fax 413-587.1272 Plot/Site Plan b
Other Specify____ _
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I'AIJI+// illLy/ 4-
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map _ Lot Unit
Zone Overlay district
Elm St.District_._ ____ CB Distric# ___
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LoLer cc, f-fa- o i O 7
Name' ) Current MaiIi< <,Address:
-. ,6--
n P
JT
- Tele ne;
263 RYAN RD BP-2014-1022
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 143 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2014-1022
Project# JS-2014-001772
Est.Cost: $11000.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 12022.56 Owner: ANDERSON DONALD E&CAROL CRAM
Zoning: Applicant. VALLEY HOME IMPROVEMENT INC
AT. 263 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:41812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 4/8/2014 0:00:00 $66.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner