23D-001 (2) 1
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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