24A-173 (2) i ms plan is me propnerary wont proauct or vaney home improvement,mc.l vnq.it is oeuvereo ror me urrureo ana exausrve purpose or supponrng me contract aia or vrn,ana customer agrees roar me elements or mis plan snau not oe repuaasneo or presemea in any
form for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHi.
Valley Home Improvement, Inc. 301 PROSPECT HEIGHTS SCALE:SEE VIEW SHEET NUMBER
MA
340 Riverside Drive, PO Box 60621, Northampton, MA 01062 NORTHAMPTON, POWDER ROOM DATE:10.1115
Office Phone 413.584.1522 Fax 413.585.0820 KORS DRAWN BY:S.G. 7
Find us on the web at: wuwYalie Homelm rovement.com REVS ReWS 9
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Valley Home Improvement, Inc. 301 PROSPECT HEIGHTS SCALE:SEE VIEW SHEET NUMBER
MA
340 Riverside Drive, PO Box 60621, Northampton, MA 01062 NORTHAMPTON, POWDER ROOM DATE:10.1115
Office Phone 413.584.1522 Fax 413.585.0820 KORS DRAWN BY:S.G. 7
Find us on the web at: wuwYalie Homelm rovement.com REVS ReWS 9
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212 Main Street
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Northampton. MA 01060
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r Department of Industrial Accidents
'' Off ice of Investigations
600 Washington Street
Boston, CIA 02111
www.mass.gov/dia
N�1"Grkel:s` Campensatian Insurance Affidavit: Buildc-rs/Cantr actGrs/ iectricians/Piumbers
Applicant Information Please Print Let ty
Name (Business/Organization/Individual): ,GE ���
Address: K k V
City/State/Zip: (�l N'1 C �� A 1%e #: �����`��2-2-
Are you an employer? Check the appropriate box: Type of project(required):
1.[' 1 am a employer with 4. ❑ I airs a general contractor and 1
employees (full and/or part-time).* have hired the sub-contractors 6. E] 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. F-1 Building addition
[No workers' comp. insurance comp. insurance.
required.] �. ❑ W e are a corporation and Its tO.r" i iGC-u7,Cal rC�iiatta t/t addlitte-ttn-
3.❑ 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' 131-1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infortnation.
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. pp��
Insurance Company Name: &be a-
a
Policy#or Self-ins. Lic.#: 00(Jc5060 2_ 1 Expiration Date: l I
Job Site Address: c:X) 12 It—s City/State/Zip:� ��L
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 rification.
I do hereby certify r�!: the pains la'dpenal/ti� peerjury that the information provided above is true and correct
Si ature: a / t-ie(J' -� Date: Z Is
a
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#:
City of Tlortha.mpton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affdavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by: V ��--
The debris will be received by: &
Building permit_mimber:
Dame of Permit Applicant 1A kyal T
Date Signature of Permit .Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:_ � (1
License Number
3c X124 Ica
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable 0
/05SV3
Company Name Registration Number
Address {{n,� Expiration Date
Ya bz 41.12 Telephone �
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....... K No...... ❑
11. - Home Owner Exempti®n
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 750, 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,oil 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 fi•om 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 153(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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ® Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [M Siding[❑] Other[a
Brief Description of Proposed
Work: FL xm a Le- S w O ciu ' 10, 0 Sl itUcTuim L CA AN C)i-- Cb FP—/ M/ ("f
Alteration of existing bedroom Yes '/, No Adding new bedroom Yes x No NEW W w i otws Ji 4J y
Attached Narrative Renovating unfinished basement Yes _�No
Plans Attached Roll Sheet jST N(� D N(3S
6a,if New house and or addition to existing housing, complete the following:
a. Use of building :One Family Two Family Other
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. Masscheck Energy Compliance form attached?
h. 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
I, L f� � � as Owner of the subject
property
hereby authAb -
to act on my elative to work authorized by this building permit application.
Signature of Owner Date
I, _ �� ' �� 4`YY\ i'1 ,as Owner/Authorized
Agent hereby d clare 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.
Print Name / <
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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: ssued for/on the site?
jli YES 0
NO _.. . DONT KNOW Q
IF YES, date issued:
IF YES: Was the permit recorded at the Regis y of Deeds?
NO 0 DONT KNOW / YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of ater or.wetlands? NO Q DON'T KNOW 0 YES Q
IF YES, has a permit been or nee to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the pro erty? YES Q NO Q
IF YES, describe size, ty a and location:
D. Are there any propose changes to or additions of signs intended for the property? YES Q NO
IF YES, describe ' e, type and location:
E. Will the constructi n activity disturb (clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb ver 1 acre? YES a NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•` Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
0 212 Main Street Sewer/Septic Availability
N z Room 100 Water/Well Availability
W 02 �z Northampton, MA 01060 Two Sets of Structural Plans
nl o phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
M Other Specify
LICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
71 -SITE INFORMATION
1.1 Property Address: 11 This section to be completed by office
Pr ec), '�`Pi �l�S Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing-Address:
C
Telephone
Sig ature
2.2 uthorized A ent:
NameN Print)
�A.Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS—7
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 3i UL-)D (a)Building Permit Fee
2. Electrical 2, o o (b)Estimated Total Cost of
J Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection `V j �r��
6. Total=(1 +2+ 3+4+5) Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0491
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 301 PROSPECT HGTS
MAP 24A PARCEL 173 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid c
Building Permit Filled out
Fee Paid
Typeof Construction:_REMODEL KITCHEN&REPLACEMENT WINDOWS.
RENOVATE 2 BATHROOMS&REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accesses Structure
Building Plans Included:
Owner/Statement or License 106006
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOPMATION 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 Permit 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 Commission Permit DPW Storm Water Management
Demolition Delay
Sig re o B i d' g ffi ial 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.
301 PROSPECT HGTS BP-2016-0491
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:24A- 173 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0491
Project# JS-2016-000828
Est. Cost: $91700.00
Fee: $596.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 43211.52 Owner: KORS STACEY
Zoning: URA(100)/ Applicant. VALLEY HOME IMPROVEMENT INC
AT. 301 PROSPECT HGTS
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:10 11512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & REPLACEMENT
WINDOWSjVA50Qg4 A4604INNOV28AM, & ptaO ft116N"11 1#1 OWS
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 10/15/2015 0:00:00 $596.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner