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17A-123 (3) Q CNAINP�, OCT 2 Q 1999 Gflit�: of Naz#[jantf lan ; � � �laasarEinsttta DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street a Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, Nelson A. Shifflett / Valley Home Improvement, Inc (licenseG'permittee) with a principal place of business/residence at: 320 Riverside D iy Nor hampton, MA 01050 (phone#) (413) 584-7522 do hereby certify, under the pains and penalties of perjury, that: n I am an employer providing the following worker's compensation coverage for my employees working on this job: Travelers Insurance Co. U13888139983 2/1/00 (Insurance Cody) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, gener4l 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/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (anach additiocW shed if neocssary to include infamarioa pataining to all 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 whilo homeowners who employ persons to do maiafeaaace,eomttuctioa or repair work on a dwelling of not mote than throe units is which the homeowner rides or oa the grounds appurtenant thereto an not generally oomickred to be employen under the vmrkees oocnpcasation Act(GL152fs i(5)),application by a homoowner fora ficrase or permit may evkknoe the legal r,--a of an employer under the Workees Compensation Ad I undereAnd that a oopy of this statement may be forwarded to the Depastmeos of Industrial Accidents'Office of Insurance for the coverage verification and that failure to segue covaago under section 25A of MGL 152 can lead to the imposition of criminal penalties oomisting of a fine of up to S 1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a fum of 5100.00 a day against mo. Signed this /,4 _day of_Oe IL 1999 For depatto mtal use onty Permit Number Map# Lot# Signature of ti enrn > z 0 i O M m cu 3 z m Its _ o-� R S G O rn tT7 O 'v a Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. J �� 2 Alterations a NORTHAMPTON, MASS. /G 19 Additions APPLICATION FOR PERMIT TO ALTER Repair Garage 1. Location 3 3� ��1 '` - �' of No. 2. Owner's name �7�f1 f N�71h9/✓ %z JG/Cf� Address ✓50 Zlle/�� Nf 4-Y ax) S r1i G/2flT 3. Builder's name i/ �Y itd /P °off- ��i 1 G Address 311_> ..e%G1.".'S �� /L- ��'0�21V Mass.Construction Supervisor's License No. n 3 nG Expiration Date �� C") 4. Addition 5. Alteration r�ifl�Q tZ " 6. New Porch 7. Is existing building to be demolished? 8. Repair after the fire 9. Garage No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof 13. Siding house 14. Estimated cost:- The undersigned certifies that the above statements are we to the best of his, l knowledge and belief. Signature of rtsponsible appicam Remarks M.R.SHEETROCK WA LS A CEILING TO REMAIN TILE OVER WIRE LATH 1.6 OWER {1SH t'J CAMBRIDGE TUB C DELTA VAVLE TILE OVER DUROq PE )SINK/MIRROR ABOVE WP CLEAR CHROME ALU D OR EC. OO 1 O / Q.T.FAN LIGHT ON TI ER / k FOUR QQOR FULL HEIGOT 1 STORAC.E CABINET WITH MAPLEI NOSING AT 36" N ADJUS BLE SHELVES -b 10" X 35'HIGH PAINT GRADE 3 3 O WORK HER BASE CABINET WITM MPPLE TOP/ADJUSTABLE PU SS SHELVES ABOVE A D VOLTAGE LIGHT RETRIM WINDOW AND DOOR TUCKER BATH REMODEL 330 BRIDGE RD. NORTHAMPTON 586-9370 L/ ©Valley Home improvement, Inc. 1999 7 Not to be dupcated or und for any purpoee wWaA wrfttm pem"sfon of Valiay Home Improvement, Inc. 320 Riverside Dr. P.O.Box 60827 Nortt�arrrpton,MA 01060 Tat 413-UW7622 Fax 413-685-0820 I s 10. Do any signs exist on the property? YES NO IF YES,describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO IF YES,describe size,type and location: 11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled in by the Hnildi.ng Department Required Existing Proposed By Zoning Lot size Frontage Setbacks - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg &paved parking) # .pf Parking Spaces f of Loading Docks Fill: 4 vol-ume--& location) 13 . Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. .1 DME: l -�`/� �� APPLICANT's SIGNATU�,, "- t" NOTE: lasuanoe of a zoning permit does not relieve an a - 9 P ppli nt's burden to oompty witi�,.$ll zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works and other appliomble permit granting authorities. FILE # OCT File No. d"� o�0 t ZONING PERMIT APPLICATION (§10 . 2 PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Aplicant /�'o 7 /—z 6e?W re" 04,5516z— Address: j�0 /��/� l /� �.e ��yei�f11n1/�iairJ Telephone: 2 2. Owner of Property: C/tip f�J61j1/"771A&- Address: 3-L d eel�6 ALIZZ ��IY flTelephone: 3. Status of Applicant: Owner s Contract Purchaser Lessee �r _,Other(explain): C 4. Job Location: o I/ Parcel Id: Zoning Map#� Parcel# /�3_ District(s): (TO BE FILLED IN BY THE BUILDINGi DEPARTMENT) 5. Existing Use of Structure/Property 6. Description of Proposed Use/Work/Project/Ocfupation: (Use additional sheets if necessary): 4910 VI 4a 4- /� � �/iv �.L — �1:�? Gj/fl�f L °c-t- CAI- 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files. 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Z DON'T KNOW YES IF YES,date issued: IF YES: Was the per ' recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# 9. 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: (FORM CONTINUES ON OTHER SIDE) File#BP-2000-0428 APPLICANT/CONTACT PERSON Valley Home Improvement,Inc ADDRESS/PHONE P O Box 60627 (413)584-7522 PROPERTY LOCATION 330 BRIDGE RD MAP 17A PARCEL 123 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 Typeof Construction:_REMODEL BATH 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 I THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § _w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 Commissi 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. 330 BRIDGE RD BP-2000-0428 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 123 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2000-0428 Project# JS-2000-0740 Est. Cost: $7500.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Valley Home Improvement, Inc 060300 Lot Size(sq. ft.): 9713.88 Owner: TUCKER JONATHAN&GINA L Zoning URA Applicant• Valley Home Improvement Inc AT: 330 BRIDGE RD Applicant Address: Phone: Insurance: P O Box 60627 (413) 584-7522 Workers Compensation FLORENCE 01062 ISSUED ON.io/2711999 o:oo:oo TO PERFORM THE FOLLOWING WORK.-REMODEL BATH POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 Shmature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 10/27/1999 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo