10-003 (2) 362 KENNEDY RD BP- 2011 -1001
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map.- 10 - 003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category INSULATION BUILDING PERMIT
Permit# BP -2011 -1001
Project # JS- 2011- 001631
Est. Cost: $2039.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 128066.40 Owner: KRIS THOMSON
Zoning: RR(100) //WSP Applicant: VALLEY HOME IMPROVEMENT INC
AT. 362 KENNEDY RD
Applicant Address: Phone: Insurance:
340 Riverside Dr (413) 584 -7522 Workers Compensation
NORTHAMPTONMAO1060 ISSUED ON. 6/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK. - INSULATE ATTIC,ADD PROPA VENT
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 6/6/20110:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -1001
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE 340 Riverside Dr NORTHAMPTON (413) 584 -7522
PROPERTY LOCATION 362 KENNEDY RD
MAP 10 PARCEL 003 001 ZONE RR(100)//WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: INSULATE ATTIC,ADD PROPA VENT
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ,RMATION PRESENTED:
_IZApproved 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
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.
-�o r re- t; V Z
of Northampton
riding Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413 -587 -1240 Fax 413 -587 -1272
i
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINQ
1.1 Proosrtv Addnass
rl
2.1 Own t�
Lr i� s� a(AA sa 3�pa kennezb RCS . leecl,s MA 010-5
K Telephone
L2 Au*Wtzsd Agent: N elSO n S h i -W I fr
'\1a- Home - PO PbX � o( ,) & a - 7 Fio A atC(a�-
Nwe (PdMU Current Mailing Address:
yi3 - 75a
Se Telephone
- +i
Item Estimated Cost (Dollars) to be �b
comp feted by it applicant
1. Building��F
2. Eiedrical 1�+NtbdTot�+l
3. Plumbing
4. Mechanical (WAC)
5. Fine Protection
6. Tota1=0 +2 +3 +4 +5) (7
'� `
� stkt }ode
s'�
f
�f+ ?;...
g
.,.,�
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 I L: R.
Rear
Building Height �– F
1 Bldg. Square Footage' % �-
Open Space Footage %
(Lot awn minus bldg & paved
# of Parking S paces
I
Fill:
volume & Location
i
! A. Has a Special Permit /Variance /F ding er been issued for /on the site?
NO O DONT KNOW YES 0
IF YES, date issued: ^!
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES o NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (dearing, gradi ex ation, or filling) over I acre or is it part of a common plan
that will disturb over 1 acre? YES Q NON
IF YES, then a Northampton Storm Water Managemertt Permit from the DPW is required.
i
New House Addition E3 Replacement Windows Alteratlon(s) E Roofing
Or Doors
Accessory swg. 0 Demolition E New Signs [oI pecks { D SMm 0131 oMer
Brief of Proposed J Le CM IL cJ !3 `! Cell ojo'v— am &q Veri
Alteration of existing bedroom Yes No Adding new bedroom Yes N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
I
I
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c_ Is there a Wage attached?
i
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
L Is construction within 100A of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cedar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
" I SPI
1,
L s as Owner of the subject
property ) �{
he authorize e sor, ! , le i I H Co -) J2 f YlU Z
to act n my behalf, in all matters relative to work authoriked by this b ikiing permit appl" 'on.
-5 1O
Signatu r Date .
1, I�U 5 �( L It�tn� L {Q�je Qy asOwner/Authorized
Agent hereby declare that the state n4ants and in rmation on the fbreboing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
N&'or7 6ht-F ie-4 -
Pnnt 14ame
b tl /
Signature /Agent Date
`
. .
`
SECTION 8 - CONSTRUCTION SERVICES
.1 Lic-ensed Construction Supervisor: Not Appkablo r
Valley Home Improvement, Inc. Licensc Nurnher
340 Riverside -Drive,—No _9/22/11
Expration Date
9. Re istegei Home I
Not Appk
ExPiration
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, 25C(6))
result in 1�.e cenial of the issuance of the bl.Wding permit.
1 1 . - Home Owner Exemption
lhc current exem kr`homovwno,i' was cxtend,dmindodo QLw 11
l'onc(i) or nvo(2}1111111lics
and maUnv Such homeowner to on-Itgenn individual for hire who does not possess ��
as supervisor. CMR 780. Sixth Edition Section 108.1-5.1.
Definition of Homeowner Person (s) ivho owna parcel of')aiid on wj res 01 in'czrds to rvs;dc on
. person who constructs more than one Itonic in a two-year period shall not be considered a 11011leown" r.
Such - hoincowner" Shall submit to the BUilding Official, oil a Conri acccmablc- to the BUildinL Official. that he/sh-
responsible for all such work perfornied under the building perwit.
Con of 11 wor';� lbr which this permit, iS issued,
Also be advised that reference to Chapter 15- (Workers' Compens"Ition) and chnpter 153 �[JabilitY
FITIPIOVeeS f0Y injUries not resulting in Death) of the
0 Massachusetts General La"�'s Annotated, you rn_gLj)v I! Lj j ) ] L � lo p sk)jj s ,,
you hire to perform work for you under this permit.
✓�za °arner A & a sines s e- elation License or registration valid for individul use only
tea\ Ofiice.of Cous+nncr Affairs & Business Re;ulation b
j si � fk
HO ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Re ulation
Registration: - 105543 Type: g (Expiration;,_ 7/17/2012 Private Corporation
10 Park Plaza -Suite 5170
_ Boston, MA 02116
VALLEY HOME IMPROVEMENT
Nelson Shifflett / a
3
�
40 RiversideDr. 4- - 1 /iiA!<
Northampton, MA 01060 Undersecretary N slid without signature
y r o�+v b
�r Samrd of Bu loin, Re tiintions mid St-Ind-ti
J3-pef'/ -.i.. i ! erase
:one- Ind T :mil / C: e"linas
License: CS 60300
NELSON A SHIFFLETT
340 RIVERSIDE DR PBX60627
FLORENCE, MA 01062
9122/2012
t us;u++isL,ncr l r=: 2383
4 ct+µrpT
goo CriN of 'Wart4aiupfutt L
ama34R[{�nSa115
�t
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ` Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION riSURANCE AFFIDAVIT
L5 6 4 5H i i -�� — 7 1 , �/ /w 4- '
(licens=/permittee)
with a principal place of business/residence at:
3 `to (phone #) j
(stx�t/cityl�,zfazip) Fwd ��
do hereby certify, under the pains and penalties of perjury, that:
(0 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
( Insurance Company) (Policy Number) (Expiration Date)
() Y am a sole 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/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) ( Insuuance Company/Policy Number) (Expiration Date)
(attach additional sleet ifnezt a to include information patmiving to all conk= ors)
() I am a sole proprietor and have no one working for me.
() I am a home owner performing all the work myself.
N0'11: p! =F- !;.- sv^r that 6cmv'wr�,�; a vAso vmpioy paaom to do r,= .true o crostn ion or rcpaa work on a dwediag of
not moan than three uads in wfz ch Ome � retidc or oa'� - �.,� ap Puz t4rsx�o are not g Ily c�idac�ti to t>e
employm uncles tlx: worker'. on np=xtiaa Act (GL152,ss 1(5)}, appUcatioa by a horneow= for a li or ptrolii may evid the
lepi ruttur of an emQloyor under tho Worker's Co avtnnt-o n AcL
I undcsz. -od diA a copy of this --- .say to f-wrrded to eha Dq t.a of ladxrsrial Axadea& ofoe of Irwuw for the
coverage verification and that failure to r^w-= coverage under section 25 A of MGL 152 can lead to tba imps Oa of aimmal penalties
consisting of a fine of up to $1,500.00 and/or imprisa of up to ow year and civil penalties in the form of a Stop Work Order and a
firm of 5100.00 a day agpimt m J°`
Signed this _da of / G 4 For dgratavnW use only
Permit Number
M Lot #
Sim.: �:� of �enseeirermittee � �