11A-059 (2) 1.07 FRONT ST BP-2005-0726
GIs#: COMMONWEALTH OF MASSACHUSETTS
ivtao:BIColc IIA-059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Pemrit# BP-2005-0726
Project# JS-2005-1006
Est Cost$2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License.
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sq.ft.): 42950.16 Owner: SCHIFFMAN LAWRENCE S&SUSAN V
Zoning:URA Applicant: Valley Home Improvement. Inc
AT.- 107 FRONT ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON.-1/18/05 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL 2 DINING RM WINDOWS
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 Deoartment 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:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 1/18/050:00:00 19095 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
-' ,�t`' Department use onry
tit of� rpld.
Northampton Status of Pg
Buildirt,g Department Curb Cut/DrTiv2v7afru[nit '
2i2iYt In Str6etaewen aepbc Av iIa lly r
N c 205 Roo 100 War/WellAvaflabihty
JP. Northampto MA 01060 Tw.Sets her of Y c(ural Plans ti
phone-4-13-587 124 Fax 413587 1272 Plot/Sde PI ;
OtSpec "7p �k
APPLICATION TO CONSTRUCT,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
lo i 'O/IT 5� Map _ Lot Unit
O�0 s3 Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
� C
s SCIS Sc Hi -�� G� f S m/d
C7/a"
Name-T-0 cnent Mailing ACdres1'.
r1
c �-t�ClvJ'e= Telephone
Signature V Vr(�
22 Authorized Agent, Nelson Shifflett
Valley Home Imarovement Inc P.O. Box 60627 Florence NA 01062
Name(Print) Currect Mallin,Address'.
584-7522_
Signatur Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use CNy
completed bv oermit aoil
t. Building SU Ll s?, (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
S. Fire Protection
6. Total =(1 +2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings nate
i
Section 4,
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This celu to be filled In by
Building Department
Lot Size
Frontaee
Setbacks Front
•N
Side L:—R:— R:_
izear , l
Building Height
Bldg. Square Footage 51.
Open Space Footage
(Loc area minus bldg&paved
arAin
#of Parking Spaces
Fill
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0� L11 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 ri DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Date issue.':-
C.
ssuedC. Do any signs exist on the property? YES NO i
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:
. ..... .........
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
0r Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ j Other IIII
Brief Description of Proposed Work: // &w( .nM d rA r'y 'vCr&q o,4,4 i
Alteration of existing bedroom _Yes No Adding new bedroom Yes No
Attached Narrative.- Renovating unfinished basement _Yes No
Plans Attached Roll _ Sheet
Ba. 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
Is there a garage attached?
d. Proposed Square footage of new co struction Dimensions
e. Numbs, of stories?
f. Method of heating? Fireplaces or 'Noodstoves Number of each
I
E'.ergy Conservation Compliance. Lt& F((/Ajif.L�ofascheck energy Compllance form attached?_
Type of construction /
I. Is construction within 100 ft.of wetlands? Yes moo- 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 .
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
1 /�S l^ /r/w/�!fGCG S6&112! /l as Owner of the subject property
herebyauthorize Nelson Shifflett Valley Home Improvement to act on
my behalf, in
all matters relative to wor horized by this building permit application.
Signature of Owner Date
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.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name
SECTION 8 -CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: 7NotApplicable CI
Name of License Holder: Nelson Shi E£lgtt __ 00Valley Home Improvement, Inc. mber
340 Riverside Drive. Northampton MA 01060 9/22/06
Address Expiration Date
584-7522
Signature Telephone i
9. r d eXe ImprovementContractor Not Applicable ❑
Valley Home improvement Tpc . 105543
Company Name Registration Number
340 Riverside Drive 7/17/09
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 provitle this aRidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... X No...... 17 j
11. - Home Owner Exemption
'fhe current exemption for"homeowners"was extended to include Owner-occupied Dwellfnes of one(l) or mo(2)families
and to allow such homeowner to engage are 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
�ruemrcS.A ae so whu constructs more than one l:ontc is a two-year^criod shall net be considered , home^a,
Such"homeowner"shall submit to the Building Oficial,on a form acceptable to the Building Oficial,that he/she shall be
responsible for all such work Performed under the buildine permit.
As acting Construction Supervisor your presence on the jab 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 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,von 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 Stale Building Code,City of
Northampton Ordinances, State and Local Zoni L s and State of Massachusetts General Laws Annotated.
Homeowner Signature
i= "e GiN of 'Nal-fllanlpfall
s e A.....ho.m. ):
DEPARTMENT OF BUILDTNG INSPECPIONS
212 '.blain Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMAVrr
I, Nelson Shifflett,_ Valley Home Improvement, Inc. _
(lio-sec/permincc)
with a principal place ofbusiness/residence at:
340 Riverside Dr. , Northampton, MA 01060 (phone'!) 584-7522
fsvct/drv!�W��;unl
do hereby certify, under the pains and penalties of per-Jury, that,
()Q I man empioyer providing the fohowine worker's compensation coverage for my
employees working on this job:
Acadia Insurance Co. 01. 09302-102/1/05
(Insurance Company) (Polies Number) (Emir ion D-uc)
O I aur a sole proprietor, general contractor or homeowner(dreie one) and have sired
the contractors fisted below who have the foilowing worker's compensation Policies:
(Name of Conmcm:) (Insurance Compmry/Pohcr Number) (Hmirntion Datcl
(Name of Cootr.:aor) (Insurance Compaay/Policv Nuinmr) (E�pimnon Daze)
(Name of Coulraotor) (Imor=c Company/Pol—y NnmFzq (EN—Ouu on Dates
(Name of Contractor) (Insurance Company/Policy Number) (EX—Uua Daze)
(.arh addili,mldaet ifaxmvym ad,de ief.,a;o.om�.s m.l:oaw.e,)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
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rpt maet W.ee cert.isw 6 U 6ommw.ermdemmtheHmod+apPURemm 0,mxo eR opt,.Hy cndvatm he
ea 1uodcrlbe vka'saPaaim Aa(GL152p1(5)).ep Waoaa bfahemmwarf aflame a pnod a.Y a+dmoe `ue
legald at— Watef.Caoom.tioa Aa•
T unda.uad ihnaagyorWi..blaeeoamaYOmw anvu f tb.
mvcvy<vctiGp>;oo eadthettil—W—waemgo ruder vGioa 25AdMGL 152 m Iu WWeb pa.6mds.+ .l Pmalva
aau,ai,ofa fiat of,W Sl}00.W..Ner ofap bamywe ititil pcmY'e is6 f o(.Sbp Watt aeda
fine o(5100.00 a day app&me
Signed this /a da of CA 0 t Far ,..emy