25A-067 ado G�V-s�o�
� � �aSaRCllnSf{{g _J
cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
O�y SJ'y�
Northampton, Mass. 01060
WORKER'S COMPENSATION !NSURANCE AFFIDAVIT
I, Nelson Shifflett - Valley. Home Improvement Inc .
(li censee/pex nli ttee}
with a principal place of business/residence at:
340 Riverside Drive, Northampton,MA 01060 (phone/#) 584-7522
do hereby certify, under the pains and penalties of perjury, thal:
( I am an employer providing the following worker's compensation coverage for my
employees working on this job:
A.I .M. Mutual Ins. Co. WMZ8005610 01 2008 2/1/09
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner(circle ogle) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (In =cc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contactor) (Insurance Company/Policy Nurrib r) (Expiration Daze)
(Name of Contractor) (Insurance Corrij,- y/Policy Number) (Expiration Date)
(nttach additional sheet ifnoanary to inch,do iLfarmaEon p=tn;niLg to all occGra rs)
( ) 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 whilo homcowixra who employ pcaam to do maiajcmtnee,construction or repair work on a dwelHag of
not morn than thrm unds in winch the homeowner resides or oa the gfouads appurtenant thado arc not gear ally cooridcred to be
eutployexs under the worker's c mpctsaticat Ad(GL152,ss 1(5))�application by a homeowner for a Uot=cc pernit may evidcmc tho
legal status of an employor under di i Workc?a Comperrmtion AcL
I understand disc a copy of this stalcmeat may be forwardod to tbo De{sutrncat of Iceia-send Aocidrni Offioa of Insxxuunca for this
coverage vcr fication and that fails=to sea=covcraga under section 25A cf MGL 152 can le_d to the imposition of criminal penalties
consixag of a fine of up to S1,500.00 and/of imp;isommcr,t of up to ors year and civil pcaaltics in the fam of a Stop Work order and a
fine of 5100.00 a day against me
Signed this / L ____Cl1-y Of YV` d ac d For dg=t <nt1 use coly
Permit Number
I oAlw?'allMa*,tP Loth
/V,z
~
°
SECTION 8 - CONSTRUCT]ON SERVICES
,I Licensed ConstrLICU011 Supervisor
Not Appilicalolke D1
Name of License Holder Nelson Shif f lett 060300
Valley Home improve ment Inc Nuinber
340 Riverside Drive
Northampton, MA 01060
---Telephone 584-7522
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(G))
�`,Iorkers Compensation Insurance affidavit must becompleted and submittled with this application, Failure to provid,,,'., -.1his afficavit
,vill res,lilt in the denial of the issuance ofthe building permit.
^^ _ Home Owner Exemt)tion
l'lic mnent exemption fox'�oomcov,ms" wa»oxtzndcJ to inc|u& [ouc(|) or xvo(l) 6mi|ieo
Lind to a|hv such homeowner tnunga(geoo individual For hire who does not pnasesnu license, provided that the owner acts
as supervisor. CMR 7M Sixth Fdition Section 108.3.5.1.
Definition of : Person (s)who oxnu parcel n[|uuJmn which bu�bo resides cv intends m reside,un which there,
is, oris intended to be, o one nr two faui\�dwn|Uog,,attached orde/achodmmcmn:smucuxsoryto such use and; nr/'an)
s|muoos. A person who constructs moi*e than
5uoh'`homuoMncf ShxU uuhmi( to the Bui/Jio-OfficiuL on a 6/nn xczopmb|c W the UuU0i//(1 Official that b0shesimll be
responsible for allsuch worh performed under the building perinit.
Asxzdoo Construction Supervism your Me,u/uzonthujobsiuwiUbcmqoimdFrunbmctn /imc- du6n'-' and
u�cn
cnmp)clioo of the work for which this permit ioissued.
Also bc advised(hm,/itbro[cccocumChnp/rr 152 (\Yorkcrs` Compcosmion) mid Chapter |5.� /|jahi|kyofI-,onpby:n/o
Tbup\oyeuo for injur\cx not resulting \n Death)ofthe 0ae`o6oscnS6onem| LuwsAnnwu|cJ` vott may be liable ib/pers^n(s)
you hire N perform work for you under this punni/.
The undcoiLnied 1mmcnxocr^ccrti5os and xoumcsnxponsi6Uity for compliance with the Dia(o Building Codc, Ci?y of
Northampton Ordinances, State and Local Zown'- Lmvs and State of Massachusetts Gcncral Liws Amiotatcd.
ilomxovour8i-uah/rc_______
5• DESCRIPTION' OF PROPOSED WOM(chekdLpDp hl��)
"Nevv How:e 3.1 I edition C1 Replacement Window,, Alteration(") Q Rocifing
Cr Doors f--1
Accessory Bldg. 0 DemolitionO New Signs Decks Siding Other
17 0,/K-
Atterw.mn ?,if oistmp, Y�t \1
A;l lip, ne ye',
Flar's �-,Uzich"d R�11
Att,:xhi�u' Yt
63. If NNW 11OLISe and oe'addition to exist i 'h6bsin comblete''the follovifin�,
Use c1t budding, One Family Two Family Other
h. Nt.,tll 10�71-r 01 r c�o,--n F, i n e a c h Ta in,i 1 j n i t: or �-tNcum(s
1y a garage
fcot?t,e (it oeev construction
Methc•j of htotmgo ar of Lack
-scheck Encrgy CCrnpH-.11,--C lorm attiichedf?
<A Cr EtttE cucn
Yes No. Is within, 100 5•r. %<xlplalrl yfiS _No
t!s C f.; I,t f t i w 0 4
I ittlir) 1D ft, (
voor t)(-Iovi iii" shed gf"716e-
k, Will -*uddinE;cor,(ofm the r3u.1d't nE a ng and 2onu yc�-
y S
City V,(�Iter Supply
IMCTIMIN icy -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM11T
as 0-,;ner c-f U'le subject prop-,rty
Nelson Shifflet e
t _Y4,11 y, 70 act N1
IC11t:"S r0ati Ve W k aUthcrQed- by this b,,Mdirog pei in't fr,tl?iiC:tier ti.
Signature of OrMelr Date
izf.,,J A&M
here-by dccfdrc ihn' t'hv sfateme"It-, -'.11d, infolulatton On t1w (01tj�,oirlg ap(.1Fciti"'11 ar(,4 ",-ua and iIccurate, to 1he L)Le�,, u'l lily
S i e d -m de r ',fic pn ---t-1 ar-,d a I t i c s Et` V. i !
7
Nelson .-Shi,tf je-t,t_-,--
p
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. ce tio
NO DON'T KNOW 4,
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:
M1
a.
Department use or:iy
City of Northampton Status oT Perrnrf>
Building Department Curb;Cu�lDrivewayPErmrt
212 Main Street Sewer/Sepnc Avarlabrlrty
Room 100 VYate /Vdeli Avarlabrlrty b > � t
Northampton, MA 01060 Twa bets of Structural Plaris
phone 413-587,1240 Fax 413-587.1272
r
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
4e /�r'o /L/
SECTION 1 -SITEINFORMATION �_ ----
1.1 Property Address: This section to be completed by office
f, ,1 Mid_ /.. t-1— `Map. Lot Unii
�' / � � Zone Overlay District
Elm St,District_ ,_ CB:District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na (P ��r,t) Current Mailin Address•
Telephone
Signature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement, Inc, P.O. Box 60627, Florence, MA 01062
Name i ) Current Mailing Address: -
584-7522
Signatu e Telephone
SECTION 3 ESTIMATED 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 (MVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) / U d Check Number 3 `
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
BP-2009-0460
GIs#: COMMONWEALTH OF MASSACHUSETTS
11 " 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-2009-0460
Project# JS-2009-000626
Est. Cost: $1500.00 n
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 105543
Lot Size(sq. ft.): 4791.60 Owner: JANDU ELAINE MOGGIO&MARK MOGGIO
Zoning: URB(100) Applicant: VALLEY HOME IMPROVEMENT INC
AT. 42 HUBBARD AVE
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.1012712008 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF SUNROOM
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 10/27/2008 0:00:00 $35.0024843
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo