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23D-001 (2) 1 4 qt Mp B oo 0.1, of Ntrz#Ilantpton _* i , �. i i� a= _ /�� + aSSiiCIJIiStttS __'_ '�W'� _' D EPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building .., Northampton, Mass. 01060 mw WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, /(/f L5 0 kr £'H / /)%L.cl` // Y /fob G0-77 l7, . L L (lipermittee) with a principal place of business/residence at: 3 , 19 , ) /LX -s J.6 a ‘ 5I/✓'2 i f/i,� -hi z4 2 i7,f (phone #) 58 `,- 7 (streedcity; sta1thip) 4 /od o do hereby certify, under the pins and penalties of perjury, that: (X) 1 am an employer providing the following worker's compensation coverage for my employees working on this job: . Acadia Insurance Company WCA5029908 2/1/2013 " (Insurance Company) (Policy Number) (Expiration Date) ( ) I 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 /Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sled if neeraary to include information pertaining to all contractors) ( ) 1 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 vitas homeowners who employ persons to do m•;++tmetr -, construction or repair work on a dwelling of not more than throe traits in which the homeowner resides or on the grounds apptutanant thereto are not generally considered to be employers under the worker's compensation Act (GL152,ss 1(5)), application by a homeowner fora license or permit may evidence the legal status of an employer under the Worker's Compensation A. I understand that a copy of this stateme st may be forwarded to the Department of Industrial Accidents' Offioe of Insurance for the coverage verification sad that failure to secure coverage under section. 25A of M0L 152 can lead to the imposition of criminal penalties consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day against tut Signed this . / 5 1 — d a y of / 4 2 0 / 4 For departmennl u e only ,Q! Permit Number /��V A". Map# Lot# Signature of L '". • ermittee 0 1ocx-vmonaleat al./leaddackuloas Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 105543 Type: Office of Consumer Affairs and Business Regulation • Expiratiop.:; Private Corporation 10 Park Plaza - Suite 5170 Boston, MA 02116 VALLEY HOME IMPROVEMEOVINC. Nelson Shifflett 340 RiversideDr. Northampton, MA Undersecretary N, and without signature Massachusetts - Department of Public Safety oard of Biliiiii112 Regulations and Standards Construction Supervisor License One- and Two- Family Dwellings License: CS 60300 NELSON A SHIFFLETT 340 RIVERSIDE DR PBX60627 FLORENCE, MA 01062 Expiration: 9/22/2012 omolissioner Trt-: 2383 I SECTION 8 - CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Nelson Shiff le..tt _ 060300 Valley Home Improvement, Inc. License Number 340 Riv -_ ' - ,• . .. 1 060 9/22/0- ----_._......._.. Address Expiration Date 584 -7522 Signature Telephone 1 4 4 4 9. Registered Home Improvement Contractor: Not Applicable ❑ Valley Home Improvement, Inc. 105543 Company Name Registration Number 340 Riverside Drive 7/17/1' 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 provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes !lfl 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 heishe 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 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 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, 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 — r Tt N 5. D SCRiPTi i,,..r 51 4 4 or PRQMVYCJIll:,0 _ . New House :LI i Addition U [placement Windows Ate ton() 2"'" Rooting CI Or Doors :.1 Accessory Bldg. ° Demolition New Signs : i Decks r i Siding [ ] Other t t - _ nectr:om _, __ Y.e _ i .,---'''rlo AP. fi: rtp. nev.; nEtrIt'nn— .,._ •Ye. _ 144- 4.1tuLite Nxtativt.t. 1;:e'r3v ii „nts 1:“.v...tursert le.., 11c, Pb: t'.t.ta:hc0 1;01: Sneet _ 63.1f New house and or addition to existing housing, complete the following: ; 0u1o1nE . C'e 7 .1.ni ty ; 13. N.ur1:tel r:.' tc0 1 each *ari',y un..t; ',41 01' S.:ithre0-r.F. I., ',.- ft+ i't a iyeage a7,tachec?" ;‹,t '10 , „;f . 11 `„,.-,,' ff I' ., C N - .1 -17.,- .• f c.:', t. VCItCd r..'f `1 1 i*::1:: ot..._:;...) ;. ',Veth„..t:ive.„ Nu- 1.;.z...- r/ U.,ICti Et, F 17,c^sercre• Oor'p ia Mctc. :nc-gy C:41ratt:e fDr-n ;...5*..tilcrce.?' Tyr& - ..t r:CI, (:),"*I": 1.1 s. OA, 'I vb t II r : 10a. 'f .c,,f wt- les ' I. c...)rtstruct.A1 w...,t tr 100 v 1 1 2J..;.rt ;• ?....w.,ement 0 cel1ar l'0or f .' k 'N1, 0.0 lOsrp: oo. form to tru`:.1.3.tiikunp uld ?vi' g 1 , 1. E.41." - e,•)1t,_______ C1`.,y Sew.r ......___ l>r yi: we.:I 1:tty v‘atctf S'..1;:v y _........_ ...,.. SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ......____.. _. .__( ' / :7 4 / ff4 : -_ . as Owner ct t: suLct rapEtty tv, ,..litnnrci , Nelson Shif flett, Valley Home Improvement, Inc . -.o::t on M . !tits 1 .•...,„A';': cli;.. )f....u . ■ ... ..... L _ .._.... - c3r)...arb......... 5 '5 71,3 sikial s .3er [.. litelaorx_Shi fle_tt, Valley Home Imprernent.„_Inc_. :')...11,- hic...eby dc2c . .hi.V. 71f: '`,, nid ir fotr. t.r. the fott!..:Roir p, iini:P : Ile t.ne cind out,:orAtt, to .11, L.>! t;° try kr cwiCC f,:!0 r, ne belief. 'ICI:7......cd ..; t.t Dil".i'Y.. ar'....1 pc:*tit t.,: Nelson SItif f lett— i- -I t . _ , — -„- — 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: Rear 4 ‘11 Building Height OP Bldg. Square Footage g (4) % 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 v DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO L/ 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 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: • rD 1.Y Department use ony of Northampton Status ofP(rt:` ! . A B ilding Department Curb Cut /c7r,veway ierl�t 9 a 12 Main Street Sewe> /Septtc Availabfirty Room 100 W' rJWell A a►labrirty ' '�� � DEPT. OF BUiLcING INSPECT)D or hampton, MA 01060 NORTHAMPTON, MA 01060 p . - - 87-1240 Fax 413-587-1272 Plot / €te Pl - Qther' specify"' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 4rif c/ 1 2 i ciry SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office /1.0A) Oi a (-/L / Map Lot Unit /// /Wa/- 1777,77? Z ,jd ! � - 1 Zone Overlay District Elm St. District , CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 64) C? /7/ ( ? /c- S" � /02 Ut wC:;ei- -71777/ / 71/ XI-- C='' l Na 'riot} Current Mailing Address: a a, Telephone Sign: re $ ✓ �~ G -�� / 2.2 � thorized Agent: Nelson Shi f f lett Valley Home Improvement, Inc. P.O. Box 60627, Florence, _MA 01062 Name (Print) Current Mailing Address: 584 -7522 — Signature/7 Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item i Estimated Cost (Dollars) to be Official Use Only _. completed by permit applicant 1 . Building (a) Building Permit Fee /SD Oo 2. Electrical (b) Estimated Total Cost of 5-0 o Construction from (6) Building Permit Fee 3. Plumbing 5 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 05 . Check Number /0'90 A/50 This Section For Official Use Only Building Permit Number: Date Issued:. __ Signature: — _._ .. Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0922 APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522 PROPERTY LOCATION 51 NONOTUCK ST MAP 23D PARCEL 001 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ,_.5/0 / 0 /S Fee Paid Typeof Construction: REMODEL BATH/LAUNDRY 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 ION PRESENTED: p proved 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 De ••lif 5 - 2 — /3 Signature of Building Of icial 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. 51 NONOTUCK ST BP-2013-0922 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 001 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- 2013 -0922 Project # JS- 2013- 001567 Est. Cost: $25000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 12501.72 Owner: BOUCHARD MARY J & JACQUELINE M BOUCHARD Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 51 NONOTUCK ST Applicant Address: Phone: Insurance: P 0 BOX 60627 (413) 584 -7522 Workers Compensation FLORENCEMA01062 ISSUED ON:4/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL BATH /LAUNDRY 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 4/10/2013 0:00:00 $150.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner