12C-066 (2) Gif� of Nart4alliptoll
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street * Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
-. ,,4eison A. Sbif L-:L 'qUqY 0M Tmprovemept Inc
(licensee/permittec)
with a principal place of business/residence at:
p'4 y j _trivet .N (4
-D aLigp n ,ik C,0 (phone 113) 5, 84-7r-22
do hereby certify, under the pall-)s and penalties of perjury, ffiat.
" I am an employer providing the following worker's compensation coverage for iny
employees working on this icb-1
American Int' l Companies WC00260737000 2/1/04
(Insurance Company) (Policy Number) (Expiration Date)
I am a sole proprietor, general contractor or homeowner (circle one) and have 111'red
the contractors fisted below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyiPolicy Number.) (Expination Date)
(Name of Contractor) (Insurer,nce Gompany,"Policv Ntufflxr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(nnach additional shoet if n6cenary to include information pertaining to a contractors)
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 employ persons to do mx=eixancq oxamxU00 or repair work on a dwelling of
not mote than three Units in Which the homeowner resides Of On the g*UodS appurtenant theme arc Dot&=erally considered to be
craployers under the worker's o=pcoution Act(GLI 52,=1(5))�application by a homeowner for a license or permit may midence the
legal dy&u of an employer under the workeet Cotnpensaiion Act.
I understand that a copy of this aatement may be fwwwtiad to the Department of lodu3trial Acc2&o&OfSoo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to tho imposition of criminal penalties
consisting of a fine of up to$1,500.00 and/or�of up to one year and civil penrics in the form of a Stop Work Order and a
f=of S100.00 a day against m
Signed this _day of For dqmtDmlw use only
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License.Holder : Nels n Shifflett__ _060300
Valley Home Improvement, Inc.
License Number
340 Riverside Drive, Northampton , MA 010,60 9/22/04_ _ __ _
Address Expiration Date
_ 584-7522
,Signature Telephone
AT �nt
2. lRaist red Ho-- prove e n Not Applicable ❑
Valley_ Home Improvement Inc _ 105543
Company Name Registration Number
340 Riverside Drive------- x_17104
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....... E 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 15 (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
FCTION 5- DESCRIPTION OF PROPOSED WORK(check all -ap_Rlicable)
�l
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing �
j Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding L ] Other Kam'
Brief Description of Proposed Work: wy,G f "" Lad uhkldw s — 4�h i+
Alteration of existing bedroom _Yes— "" Adding new bedroom Yes _.____No
Attached Narrative _! Renovating unfinished basement Yes L'No
Plans Attached Roll Shee,
6a, If New house an d or addition o existing,housing, complete the foll win :
a. Use of building : One Family Two Family
b. Number of rooms in each family unit: ____ Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction.__ Dimensions
e. Number of stories?
f. Method of heating? ___ Fireplaces or Woodstoves - Number of each --,----.-,
g. Energy Conservation Compliance. _ Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain_ Yes_______No
I- Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? ,Yes No .
1. Septic Tank City Sewer Private well City water Supply _-_
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i, Paul &.-,Helene Stracco _.. .__, as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement, Inc. to act on
in all matters relative to work authorized by this building permit application.
�_ � _ ya 2 �� --
Signature of Owner
1, Nelson Shifflett, Valley Home Imvrovement Tne_ , 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 Name
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 b}
Building Department
Lot Size
Frontage
JA-
Setbacks Front
Side I.:
Rear r `�
U
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 permi corded 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 l�— 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: _. --
r
;Department use only.
Northampton Status of Twit.
erg Department Curb Cut/fi veway rni+t
2 �,Main Street Sewer/Septic Ava#18-61#
mom 100 W :Weil AvaifabiiityEr
J•�
i JL1 3 '1 rtha;mpton, MA 01060 T r meets of Oural plans N
phone 4 � -1249 Fax 413-587.1272 Plot/Site
Otter Spe °
PPLIC 'i4kT6CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION : -SITE INFORMATION
1.1 Property Address: This section to be completed by office
21 Harold Street-_ Map Lot Unit
Northampton, MA 01060 Zone_ Overlay District _
Elm St. District_.,_ T C8 District __
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2:,Owner of Record: 21 Harold Street
Paul & Helene Stracco _ Northampton, MA 01060
Name(Print) Current Mailing Address:
584--0956
11 Cc C-) Telephone
Signature
2.2 Authorized Agents Nelson Shifflett
Valley Home Improvement, Inc P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
584-7522
19
Signa ure Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
- 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
Building Permit Number: _ Date issued:
Signature: "
Building Commissioner/Inspector of Buildings Date
h4 . , BP-2003-1228
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Pennit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1228
Project# JS-2003-1899
Est.Cost: $10000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sa. ft.): 10062.36 Owner: STRACCO PAUL&HELENE
Zoning:URA Applicant. Valley Home Improvement, Inc
AT.- 21 HAROLD ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.•6130103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE REAR DOOR , 2 WINDOWS, 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 Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/30/03 0:00:00 16750 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo