17D-039 (3) i
c
a !^�
3 d e rlaaalsc;trsctis
o DEPARTMENT OF 13U1LDIJG INSPECTIONS
212 Main Street ' Municipal Building
l�Torthnmpton, Mass. 01060
WORKER'S COMPENSATION 17,iSUR.ACE A 'MIAVU
I, Nelson Shifflett, Valley Home Improvement, Inc .
(licenserJpermlttee}
with a principal place of business/residence at:
340 Riverside Dr. , Northampton, MKA, 01060 (p;lone=) 584-7522
do hereby ceniry, under the paiP.S and pen lties or per;urv,
(x) I am an empiover pro✓?ci g the follow ng :�crr e s ccmpcas.c�cn covcr`�e rcr m.
employees working on this job:
Acadia Insurance Co. 0109302-11 2/1/06
(Inc=a= Corlp=y) (DoLic;tiun c�rj cirdoII Jet°;
( ) I am a sole proprietor, geaeral conmactor or homeoy-mer (c'rCie oLe) and hs.e airei
the contractors listed below who have the follow'112g worker's compel' -on policies:
(-47aMC Of COnLraCL. I1SLM2U1(v COIur3.0',"Po'L'Cr N'Umbc,", �C O Da--;.
(4a?le
of Comn"'Zor) tInSUIdIlcz— C0MC3--T}•!,P0liC;�'UmtC-) ! "?i:ca Date;
�Name Oi Cort (qas-Lmaac' Comp xiy/?OI
(game of Contractor) (Insurance Company/Pclic; Num ---) (-Expi-�aucII Dom)
(-n—add?ioca1 shcct ifneccsar±to ixlude infortcurioa pctain:cg to aL'Dors,--S)
( ) 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 bomeowo=wtio caploy pcscm to do rM= „ D loo of ccPas wait en i d�elLzg of
not mcrt:than throe tails in whits;the bomoowver rca e s or oa the uvjn6 zppuz'.ersui tboceeo arc no(gwcaliy Wandered to be
employca undo the svoticcts c=pcsatioa Ac!(GL 152ss 1(5)),application by a homcownc for a licertve a Pam t:ay cti^dcace the
1es2l etatus of an employee under the Workcet Compemation Act
I un�d tb,a a cary of this rul=cai may bo forwu ded to tha Depart,. i of Ind,,Uid A=d-&O`Si-of Irarnoee fat the
coverage vecificziioo and that kilum to secure covcrabo under soczion 25A of MGL 152 can It'?to use i tioa of cri.::insl PetslCc
coasixiag of a fine of Up to S1�500.00 and/or of up to one ytar and Ci vil p=ipits in the form of a Slop Went Cart and a
Lae of S100.00 a day agsinst m
Signed this day of e For dq=tM=3W usc octy
Pcrmit Number
Mari Lat r
i
i
A
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
Lot Size
Frontage
Setbacks Front �
Side L: R: L: R: f
Rear (�
Building Height
Bldg. Square Footage �o
Open Space Footage %
(Lot area minus bldg R 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 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:
C. Do any signs exist on the property? YES NO G IF YES, describe size, type and location:
u. Hre mere any proposea cnanges to ur aaQiuuns ul signs uHc PIUJJo- Ly
No
IF YES, describe size, type and location:
SECTION 8 -CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name ofLicenseHolder : Nelson Shifflet 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive Northa,T,nton, MA 01.0.6.0— 9/22/Q6
Address Expiration Date
584-7522
Signature Telephone i
1
9. R i red me Im rovemen Contractor: Not Applicable ❑
Valley Home Improvement, Inc _ 105543
Com any Name Registration Number
340 River s_ide Drive — 7/17/06
Address J 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....... 20 No...... ❑
11. - Home Owner Exemption
The current exemption for-homeowners" Nvas extended to include Owner-occupied Dwellings of one(1) or t4yo(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 11e'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 iarin
structures. A person who constructs more than one home in a two-near 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 1`oUl preSCnCC oil 01c lob SILL 1�'ll! b);rCCi JI LL1 frlI I i111iU i0 tic,
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 15'3 (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 7oning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature --
i
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all a" icable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other V-r"
Brief Description of Proposed Work: ) G �V2�L✓9
Alteration of existing bedroom Yes—j�l5o Adding new bedroom Yes o ��^
Attached Narrative _ Renovating unfinished basement Yes i
Plans Attached Roll - S*t
'T
6a. If New house and or addition to existing housing, complete the followinl7:
a. Use of building : One Family Two Family ✓ Other
1 b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
f �
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?
-ypc cf constructi
Is construction within. 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
i.
1. 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 C7,1 C:f� Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
0011 _ as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement Inc to act o;-i
my beh in all mat relati to work authorized by this building permit application.
Signat e of Ow Date
I. Nelson Shifflett, Valley Home Improvement, Inc- 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.
Nelson Shifflett --
Print Name
Department use only
City of Northampton Status of ;�f#
.. x' tLr, s
Building Department Curb Cuvurliveway P it� 4
212 Main Street � �'
Sewer/Septic Availabl
Room 100 wgor/Well Availab�ltty `= * � <�
Nortiampton, MA 01060 Tivo:Setso x ctiiralPlans
11 ' -p for 13.587.1240 Fax 413-587-1272 Plot/Site
Other Specifyrt � x
a
APP!LICATIOt+:4Qi. NSTRU T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone_ Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT n
22.1 Ow-Der of Record: ,j'7/�' ��' ��/�!7 � � f1/ �►
Name(P;{nn, Current Mail+ Flcdress:
Te:epr
no
Signature o -
2.2 Authorized Agent: Nelson Shif f lett
Valley Home Improvement Inc P.O. Box 60627, Florence, K 0106,2
Name(Print) Current Mailing Address:
584-7522
Signature f Telephone
SECTION 3 - ESTIMATED CONS T RUCTiON COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1 . 8ui!dinp (a) Building Permit Fee
2. E!ectrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing �J Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
This Section For Official Use Only
Signature:
Euildinn Commissioner/Inspector of Buildings Date
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File#BP-2005-0836
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 12- 14 HIGH ST
MAP 17D PARCEL 039 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existins,
Accessory Structure
Building Plans Included•
Owner/Statement or License 060300
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOjF&ATION 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
7/,?12czo
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.
i
BP-2005-0836
GIS#: COMMONWEALTH OF MASSACHUSETTS
k: 17p-039 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2005-0836
Project# )S-2005-1161
Est. Cost: $11000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Valley Home Improvement, Inc 060300
Lot Size(sa. ft.): 8755.56 Owner: COOK BEVERLY
Zoning:URB Applicant: Valley Home Improvement, Inc
AT: 12 - 14 HIGH ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:319105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH
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 Shmature:
FeeType• Date Paid: Amount:
Building 3/9/05 0:00:00 $55.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo