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' } DEPARTMENT OP BUILDING INSPECTIONS 4 — t
212 Main Street • Municipal Buildings ss�
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L 44z-SoA EH eg`=z_ , 7 v/f/ --✓. ;% M --)s7- '�//,/,: , ,F l /2cr1i
(licensee/permittee)
with a principal place of business/residence at: •
3 fo i/'E s ;:� _ e /±J/ ,//ate` / ;,77,iZ)A; / (phone #) °5 8 7
(st=t/city/staitip) €' c,
do hereby certify, under the pains and penalties of perjury, that:
(x) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
f e /(42 X /15. C'(.) _ lam' F6 C' 556 cs 1 2 /i / /,®
(Insurance Company) (Policy Number) (Expiration Date)
( ) 1 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 Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poli cy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining 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: pt he wars that atrilo homeowners who empioy persona to do maintenance, construction or repair wort: on a dwelling of
not more than three units in which the hon+o resides or oa th^ gr o cc;- sppurte t Mures art not gully considered to be
employers and r t worker's cottpeasatien Ad (CsL152,2s l (5)), application by a botneowuer for a license or permit may evideaoc the
legal status of an a aployaa under the Worker's Compensation Act.
I understand that a copy of thin 01st -. '--t ntay b fe o dsd to the Department of Industrial Accidents' offioa of Ii az a ce for the
coverage verification and that failure to swam coverage under sex Lion 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a ate of up to $1,500.00 arzdkr imprianem of up to one year and civil penalties in the form of a Stop Work Order and a
f i n e 0( 5100.00 a day aga izat rw..
Signed this -, day of /et, „.2 o F use only
Permit Number
7 2 f � , �_ -� ! , �'I 4 bera 'g, ,�` 10-0 Mat • Lot # _
Sig^,.ru„� of i:'`rermittee 1
SECTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable . 0
Marne of License Holder: Nelson Shi f f lett____._ ..__ 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive, - Northampton, MA 0.10.60_ _ 9 / 22 /f2.__ -_
Address Expiration Date
.lid 584 -7522
Signature // Telephone
9, Registered Home Improvement Contractor: Not Applicable ❑
Valley Home Improvement„ — Inc — 105543
Company Name Registration Number
{ 340 Riverside Drive 7/17/12.
Address Expiration Dee
Northampton, MA 01060 Telephone 584 -7522
SECTION 10• WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afficay.t
wi1 result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes X No ❑
11. - Home Owner Exemption
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 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 farni
structures. A person who constructs more than one home in a two- vear period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on 0 form acceptable to the Building Officialss at helshe shall be
responsible for all such wort. performed under the building permit.
Asa 'tin;; Coiistrnctioii Supervisor Sour pri ;enct: on the jot) site . ;:11 .:+ i,.i.1 d:.ri
completion ofthe 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 Leath) of the Massachusetts General Laws Annotated, you may be liable for person's'
you hire to perform work for you under this permit.
'I'he undersigned "homeowner" certifies and assumes responsibility for compliance with the State Builditm Code, City of
Northampton Ordinances. State and Local Zoning Laws and State of v1assachuserrs Gen Laws Annotated
Homeowner Signature
F!RC2POS:EP
Ac dititrt flediliLeltICA Wittdowf, A Lthsti::110,),,PC, RooNr.t:
CI,;; Uoctrl,
Accory bidg,. Li Dernclitii:J Nev.; Sgn dirg OthErf 1
C,,ryt9idc,1 „ Ai /441, -
6:4 If New house and or addition to existing housing, cornplete the following,
SECTMN 7 OWNER AUTliCRiZATiON TO OE CON1PLETEO WilE14
OWNERS AGENT OR CONTRACTOR APREJES FOP BUILDING PERMIT
L m •(- °1`'' - t
= ; Nelson Shifflett, Valley Home Inprovernent, Inc.
Nels.on_Shitflett,__Valley_lione_Improyerttent.,.._ Inc.
• HLA • »» Ulo
7nT
Nelson Shifflett
•
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:
Rear
Building Height
Bldg. Square Footage I r
(1J
Open Space Footage
— —
(Lot area minus bldg & 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
W 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 _
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:
, ^ ... ' ,.. ... ..
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� ���� Department use orli
.^��w' , {�i� of Northampton
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` �' ` cOP a UHdingDepartment
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" �l� �in��re�t Sewer/Septic Availability
��-.' Room 100
Wa ter/Well Availability
Northampton,
phone 413-587-1240 Fax 413-587-1272
�_______ __ ,
Other _ _' ' _
APPLICATION TO CONSTRUCT, DEMOLISH
- -� ---- --- -------'
SECTION l' SITE INFORMATION
This section to be completed by office
1.1 Property Address:
K4ap Lot Unit
—
°_� ��** Z one
| Overlay District _ ____
�~ � ~v / ^'' °v ���' -- _ "
Elm St. District_ __ CB District ____
- -
SECTION 2' PROPERTY OVVNERSH|P/AUTHOR|ZEDAGENT
l - _--
Record:
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Nani Print) Cu duran
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5igna!ure _ • __� _ __
2.2 Authorized Agent: Nelson Shifflett
I Valley Home Improvement, Inc " P.O. Box 60627, Florence, MA 03062
Name P i , Current �oi|ing Address:
y7y/ °
584-7522
/
Signatum «� Tc/ophvno
.
SECTION 3 - ESTIMATED CONSTRUCTION COSTS |
/
Item Estimated Cost (Do||arq;:o be > Offioiai i_jsc
| d b it.app/ioani
/ l BuUdin� nn
(a) Building � �n
'� ��a p
.1.... ��
2. Eiacthca| (b} Estimated Total Cost of
7
-»
���fJ�J Construction from (
Building Permit Fee
This Section For Official Use Only , _ _
Building Permit Number; Date issued:, _
B Commissioner/Inspector of Buildings 'Date
.
File # BP- 2012 -0194
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS /PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 256 CHESTNUT ST
MAP 17A PARCEL 147 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 0 X9 a `O
Fee Paid Q �$
Typeof Construction: REMODEL KITCHEN
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
INyOyNIATION 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
Signature of Building Official Date /
g g
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.
256 CHESTNUT ST BP- 2012 -0194
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 147 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- 2012 -0194
Project # JS- 2012- 000299
Est. Cost: $40000.00
Fee: $240.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 22346.28 Owner: O'CONNOR EDWIN M & DEANNA L
Zoning: URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 256 CHESTNUT ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:8/25/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN
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 8/25/2011 0:00:00 $240.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner