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VALLEY HOMES IMPROVEMENT INC,
AS= Shilet
RO Bux 60627
FLORENCE. 31062
A Kmw�mow I wt W-f
The Commonwealth of Massachusetts
Depamnent of Industrial Accidents
Office of Investigations
��• ,- 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/lndividual): � - % �-
Address: c �c l L��jT.
City/State/Zip: Z,11 -&;Y f �S 7 2—
Are you an employer?Check the appropriate box: Type of project(required):
1.[N I am a employer with )� 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.$
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.Fl 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.[1 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
information.
Insurance Company Name: l
Policy#or Self-ins.Lic. Expiration Date:
Job Site Address: 31) City/State/Zip: 1
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.
7r
I do hereby c er aims and enal7(1/,pe ry that the information provided above is true and correct
Si afore: �i�/' ,� �/' °� j Date: q
Phone#
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#:
. .
t CT
gider :-Nel. on Shiffl-ett--.- 060300
License Nun-iber
Valley Home Improvement, Inc.
340 Rivers—ide Dr 2
e, North pt*nn , MA OLO-60
Address Expiration Date
Signature Telephone
E!J Not Appkcable ED
Valley Home 105543
Company Name Rer-istration Number
Arddress Expiration Date
Northampton, MA 01060 Te!cphone 584-7522
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§ 25C(6))
Workers Compensation Insurance affidavit mist be completed and su!Drnitted with th;s application. Failure to Providethis affldawt
will result in the deniat of the issuance of the buiiding pemt.
11. - Home Owner Exemption
The current exemption for'1mmourmuo'was extended minclude one(1) or families
and m allow such homeowner noun�agcunindh� �
duurkin:wbo6o:snotpnsscs uUcxoxc, provided that*he myner��cts
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel oC land on which he./she resides or int--nds to reside,on which there
res accessory to such use and! or flann
or is intended to be a one or rwo family dwelling- ettached or detached st.
holl
Such"horneowner" shall submit to the Building Official, on a fort-n acceptable to the Building.Offlicial,that helsheshall tle
responsible for alli such work r)erformed u nder the bufldint� permit-
As acring Construction Supervisor your presence on the job site will be required from time to tirne, 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 (IJabifity of Employers to
miployees for injuries not re =1 —
N!ou hire to perform work for you under this permit.
ThC Undersi2ned"horneowner"cert-Ifies and assumes responsibiliry for compliance with the State Building Code,C illy of
�qnrdem"'"�0,�innoc��� �t�o and Ln�mi Zoningl'ays and Statcof}�ussnchuoo�sGcnon| Love Aono�gcJ
E{amuov,ilrrsignxtorc___________________
`
.,. If New house am-d or zddltion tc existing housing, cgivpIetc the followfiia-
i
1
_
1
N g„ r`:on F-1e:,E.:C.,,h C4'_,.E !f",�(,;' ,i, E;;C, f.kQ:.§F,_. ._Y';• _._._... C s
s
w. '.`a` �: ,ly Ir4"% .. ;:.6"n C(: '.''�c. l,`yJ i:'.0 S.�, .`P:i '_ C°..,.... €.�..:L.iEE.:.x;rl _ ._.....__.`i`.•%a....___.__._ p.�'
T •m i
SECT iCN 7a , OWNCR AUTUCREZAT�C N a TO CC COMPLCTED W! C14
CWNERS- AGENT CP CO °T:R.ACTC R APPLIES FOP BUILDING PEP E
Nelson Shi;�tlet.t, Valley_, Home, Inprove ent, _ Inc.
aalt
PY
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERNUT CAN BE
DENIED DID TO LACK OF IlNF®IMATION
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 /o
(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: A �� 'j
✓e �J
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:
`i „
V. LJV a,iy` JisiiJ �.niJi vi1 li C h'•.rl r.y?
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
N!t/
IF YES, describe size, type and location:
ep)rtment use or iv
ity Of Northampton tus of Permit:
�C} ilding Department Curb Cu.'Driveway Permit.
+ JUN 2 4 2Q1� 912 Main Street Sevrer/S2pticAvaila.biIity
�tions Room 100 Water/Well Availability
p}umbing&Gas InsP
NOr amptOn, fVlA 01060 �T%ro sets of Stf uct,iral Plan
E�ectrt Nortr amP ne 413-587.1240 Fax 413.587.1272 Plot/Site?laps=~
Other Specify__
i
APPLICAT[ON TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A 0I4E OR TWO FAIYILY DkrvELLII4G
Y11-y ` AG f",�-�
SECTION 1-SITE IHFORMATION
Add
Property This section to he completed by Property /., L office
157 P� C4 / J T Map - Lot _Unit _
Zone Overlay District --
Elrn St.District CS District I
SECTION 2- PROPERTY OWNERS AGENT
2.1 Owner of Record: i
Vke[qh1,--, i , ca
Na e ` t) Current MailiA Address:
Telephone
Ste. ure
2.2 Authorized Agert: Nelson Shifflett
F
i
d _ P.O. o 6Q.627,_ Florence,ra�_ejs Fo .e imroxre e t l _
-
Narnc(Print) Curren+. lulling Address:
i
584-7522 __
t.
SignF.ture Telephone
f
P"Mir�ATED CONSTRUCT 10N COSTS
Official lise or,N, ..__
fi
ccrnrleted by porm, it a olirant
1. Suiiding O (a) Building Perrr:it Fee
f
2. Electrical (b)Estimated Total Cost of I f
Construction from(6) l +,
iuinbing Suilding Permmit
z FAe 1
Viechanical (IHVAC)
E
�6. ,Ota (1 +2 L # .ru_bV I Tf
T,'` SecttDn For Official Use Cnfv
lnrr.g t'errnit Number: Date suedl:
;t a r[t.Ccr i'ssioner;'Inspector cf P.UilG11-gS it
307 PROSPECT HGTS BP-2014-1386
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 177 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1386
Project# JS-2014-002337
Est.Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sa. ft.): 18992.16 Owner: HACKMAN JANET T
Zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 307 PROSPECT HGTS
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.612412014 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 Si nature:
FeeType• Date Paid: Amount:
Building 6/24/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner