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GriN of Nartijamptall
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street * Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L NoTson A. Shifflett
Valley Home Improvement, Inc.
with a principal place of business/residence at:
340 2_,j-,TQ *de e amp ton, KA, 01060 7 5 2 2
-raL LjLtY_,___N
�Qrthant JP110110) L�13) 58
do hereby certify, under the pains and penalties of peflury, thl-
I am an empioyer providing the following workers compensation coverage for my
employees woricing on this iob:
American Int'l Companies WC 00625437401 201 3
(Insurance Company) (Policy Number)) (Expimtion D=)
I aui a sale proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies,
(Name of Contractor) (insurance Company/Po[icy Number)
(Expiration Date)
(Name of Contractor) (Insurance CoiripmyiPolicy Number) (Expiration Date)
(Name of Conmictor) (Insurance,C-orol3anvilolicy Number) ('Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additicruil shed if n6oerA"to inck%dc informsfion perudning to a oo'grmcior3)
O 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 the vAii1c homeowners who employ pc=m to do inajnicaamcr,oanstrwion or repair work on&dwelling of
not awe than tbrft units in which the homeowner resides or an the vound3 qTurtensni thereto an not generally oowukrtd to be
employers under the workers compensx4on Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workeez Compensation Act understand that a copy of this rutmunt may be forwwxi*d to tbo DtpwtmcrA of In&UStrial A=&n&offloo of l=Wranca for the
coverage verific3fion and that failure to sm=coverages under section 25A of MOL 152 can lead to the imposition of criminal PC13111tics
consisting of a fine of up to$1,500.00 and/or impx s %l of up to one year and civil penalties in the form of a stop Work Or r and a
fine of S100.00 i day against m
Signed this day of Ae C "�L For de al use ooly
Permit Number
Map# Lot
Signature of Li crmi
~
^ .
SECTION 8 -CONSTRUCTION SERVICES
.1 Licemd Constf�tjction Supervisor: Not Applicable 0
Name of License Holder Nel n Shif f-I 060300
-ett, License Number
Vallei Home Improvement, Inc.
340 Riverside 06n 9/22/04
Address Expiration Date
Signature Telephone
9. Registered Home Improve ent Contractor. Not Applicable El
Valley- Home Improvement, In 105543
CompA11-y-Name Registration Number
340 Riverside Drive-___ —7117/Q4
Exuration Date
Address
North���tqi 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.
11. - Home Owner Exemption
The current exemption 6x'homeowncrs"was extended minclude Owner-occupied [one(\) or mm(2) families
and m allow such homeowner toengage an individual for hire who does not possess a|iounxc, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3-5.1.
Definition of Homeowner: Person (s)who own u parcel u[land on which ho/d`u resides orintends to reside,onwhich there
is. oriuintondediohc, uuneortwnfami|ydwc||ing,uutaohcJnrdo«uohodxtroomreuuocoaxoryMouchuscunJ/nrbmn
structures.
homeowner-
Such^^homoowner'shall submit to the Building Official,onu form acceptable to the Building Official,
responsible for all As acting your presence ou the job site will hc required from time nn time,during and upon
completion of the work for which this permit iuissued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter |53 (Liability of Employers/o
Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated, you may be liable (brperson(s)
you hire(o 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 ❑
i Or Doors ❑
I
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other
Brief Description of Proposed Work: r O 7-6 3 Soguw i r*
Alteration of existing bedroom ___-___Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes L/ No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing ousin complete the following:
a. Jse of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
0
c. Is there a garage attached? I
d. Proposed Square footage of new construction._ __. . Dimensions
e. Number of stories? 1
f. Method of heating? �7t.� _ 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
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_ No .
I. 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
Christian & Kathryn Schmidt _- -_ -_�, as Owner of the subject property i
hereby authorize Nelson Shifflett, Valley Home Improvement_ Inc. ____-_ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I. Nelson Shifflett, Valley Home Imyrnvempnt-,_Tnc_ 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.
s
_Nelson Shifflett -- ---
Print Name
i
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
[.of Size
Fronta e ^
Setbacks Front
Side L: R:______
Rear ll
;t
Building Height
Bldg. Square Footage 0 %
Open Space Footage %
(Lot area minus bldg&paved
parking)
t: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?
NO 1---' 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
City of Northampton Status of P �z .
Building Department Curb Cut/t3rive way R, raartt
212 Main Street Sewer/Septic_AVaill Otty, .
Room 100 W /Well Availability
j
`T4orthampton, MA 01060 Tweets of tural Plans
phone 413:587.1240 Fax 413-5871272 Plot/Site P '�
2003 other Spec"t# .
y
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
✓
24 Cloverdale
Map °``-�" Lot_�. Unit,-
24
Florence, MA 01062 Zon ----Overlay District ---Elm St.District _. CB District _—._
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 24 Cloverdale
Christian & Kathry Schmidt _ Florence, MA 01062
Name(Print) Current Mailing Address:
585-0627
,.� Telephone
ignature
.2 Authorized Agent: Nelson Shif f lett
_ ley Home Improvement, Inca P.O. Box 60627, Florence,__MA 01062
Narne(Print) Current Mailing Address:
584-7522 ___
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION C05T5
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit a licant
?. Building Ci (a) Building Permit Fee
2. Electrical t (b) Estimated Total Cost of
Construction from 6
3. Plumbing 6 `7 Building Permit Fee
4. Mechanical (HVAC) f
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5} `' 0(11? Check Number A�p
This Section For Official Use Only
Building Permit Number: �d3`6C?� Date Issued: __
l Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0600
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 (413)584-7522
PROPERTY LOCATION 24 CLOVERDALE ST
MAP 12C PARCEL 051 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid A6 —
Typeof Construction: ADD DORMER&BATH&CONVERT SCREEN PORCH TO 3 SEASON PORCH,
REMOVE PATIO&ROOF&CONSTRUCT MUDROOM
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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO IATION 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 Pern it 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-2003-0600
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0600
Project# JS-2003-0997
Est. Cost: $40000.00
Fee: $200.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq. ft.): 13024.44 Owner: SCHMIDT CHRISTIAN F&KATHRYN
Zoning URA Applicant: Valley Home Improvement, Inc
AT. 24 CLOVERDALE ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413)584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:116103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD DORMER & BATH & CONVERT SCREEN
PORCH TO 3 SEASON PORCH, REMOVE PATIO & ROOF & CONSTRUCT MUDROOM
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/6/03 0:00:00 15944 qpdo—O
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo