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�
. � DEPARTMENT OP BUILDING INSPECTIONS =_`f
212 Main Street ' Municipal Building
Northampton, Mass. 01060 `'�•
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, 5.2--l/Z/V<)1L V , 1�GG ,`-� /T'6/4 F -1- 2// {/I,"1x/Z j�„/�1Z{
(licenseeipermittee)
with a principal place of business/residence at:
3 y-v 4 v"e i$1 / 1-2 r,/i JU7 /7,/:127/; Z'Vt/7//4 (phone#) f//-7 2
(tt/city/st tP:Gips
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)
( ) 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 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:please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Ad(GL152,,3 1(5)),application by a homeowner fora license cc permit may evidence the
legal status of an employer under the Worker's Compensation Act.
I understand that a copy of this rsatemmt may be forwarded to the Departmcnd of Industrial Accidents'Office of Irouraoce for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 andlor imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fate of 5100.00 a day against me.
Signed14.' _day of �:JV /4-A. ' 713 For use only
,� Permit Number
/� / //� i /-" r i Map Lot#
ignature of Li... =- "ermittee
I SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : Nelson Shiffl.ett 060300
Valley Home Improvement, Inc. License Number
340 Rivers 'd- • ' - + • 41 - 1140 • • U : 1 0..6n 9/22//6
Address Expiration Date
584-7522
Signature Telephone
•
9. Re:i teed Ho Imsrovemen ontrac •r. Not Applicable ❑
Valle Hot e • • • 105543
Company Name Registration Number
340 Riverside Drive 7117J14-
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 X No 0
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 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 he
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, 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 State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature_
. 'r-S2119N 5. DESCRIPTION or PROPOSED WORK(check oil .?,1pptic8)1q)
New House :::! 1 Addition LI Replacement Windows ! Alteration(s)ID Rooting 17
Or Doors :1
Accessory Bldg. ° ' Demolition° New Signs : 1 Decks : : Siding f ) Other : I
9.le:' DInt:-r); On r.;`, Prc-por,ec No.k "(Jed(fa , 4
4. 4 — , ..,-- .,.. 1.#1 u..i.,u .)ccitc, /0 ceii.
• ... ' '
crp 5ttr:tOnwi Ye; ...hrn AP.1./IR ri, ,,f,' nft.rirm-r, 'es
he;.; '',Iiirr,rtIvr,' P,4-7,-Ksititr?. .,11'cle',,hed12a-A-ine!I '11.n _
Pbr-'s ."k`t,:acher:. Rol: Snetr.',r..--------
,
6 , If New house and or addition to existing housing, complete the following:
u,4, :-..1 tAidc11.7. : C c 'Thm ty L.------------ Tv.° 7arnily O r
rc —e, 1 each *81"*Cy !..tf: \tl''''.",::-.E" f;•7
j31:4Lhe.(1?
J 1"re;:q0,e(.., Sc,rior!,-; 1cd,"11,:e :,r't wr:rw .7.,:.:11s tr Jr". :Al ;)i'ZieW0G.`t,
'.` "\' !" i'-' .f.Y. c.'":'!.• •• ,A
' Ve*.r0i 0' lt-.•.71:-Ie f I '.7 I.: L:::...t',_, :_lt Weed t 0 V*`..;!'..., NW` b u' each
2 F•".*Ei;Ty Cc-Sert1,7•2''nC717:,,,cr'h ia--;:c ME:sr.:heck Etry C,c,rmpliari.ce (:r11 a:taCi.CC7
I 0.C"
• '.›(:.•-.;'0,:ti,/,:t1C 7i VrthEA 1 0,) 't .:)t te■et,i,ilit".1.0 ies N.',) lir CDFIS.trUCEr.)n w thti' 100 yr "Icr,o.101a,11 _Ytr, N:j
I
1 Der,!"1 rif ow,,t,mrrht r-,r. celiac' I oor trek)../ °Ir,esalec
1
1 k Wii, r..10 kiir.F.: r..(..r-, IDt-ri to s",i, v 13udf:ttipo ;*11.:i .1arip, t44..13tIC-f,?
!
' L 142.1.1c 7a*Ik Cy ;.;:l'A4 Pt Va"..7) %%e'.1 city water Sup v
-----
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
. ------ .
CP...net Ct ,t-e Lubject p',DiDetty
tto•.,-1;:y ;:te,'.:Itint Nelsop. Waif flett, Valley Home Improvement, , Inc.
rfIR 12,2, .:.• , ,i, 1 7-1,-.Ntr!, .e..:,- ....t. la w:4",,, thilic-we4 ty, I'll; 1, 1,:,r, 112 ,,oe!r-r. a;Iplic,A1G-
5/ 5 /2-0 1 3
..... ., ....1.1
,
i
• .Nelson_Shifilett, Valley Home impx.oitment„auc, _lc .%,..1-1riAiilflfri7f,:t Acc- t 1
hc-,:ty dcci.r.fc .j.la.'. ".*.lt2 t,taternc"tt.', ltrid tclorr-vc DU (rZ the foregcm-R aor licatich trre l'ue cirld auerrrate, lo "he L>trt," L',1 ivy
1•1-rwle:crc r nr.":, belief.
St.r.Ed • •-(cc" :1-,:: DU-,':: z.-;"-J ir.::2-,a ',H2.3 u'
„..Nelson Shif f let t
I N.itnf:
zo;:i ,F.it.7.•O. .,'•,.-1•7°". ....r,
'01-0/3
71;t1t1 ,
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
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 ✓Z 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
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:
r ,e'
Department use only
Rf w-
C____,�CE_ :�'tyi of Northampton Status.of Perpilt: .
uilding Department Curb Cut/Driveway Permit
4
2013 212 Main Street SewrlSeptic Avaelat+l�ty ��
1:f
Room 100 Wte1/Well Availability , ;� '
f au;Lo,�,°; ;�___� N�+rth a m pto n, MA 01060 Twets oftsctural Plaris �
NORTHAMPT°N M� �6;°"e 41;-587-1240 Fax 413-587-1272 Flo#/Site Pi � �
Other Specify? T
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION /` 67/4 D ck-1 - 44 1,0 (�/ iJ d ecv 2i/t4.4-"�4-
1.1 Property Address: This section to be completed by office
L17), 1 t1 V"( (() -1-f."Vv't(_e Map Lot Unit
Zone_ Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
` � C�C1C� SO.,.
C�1�t �� t v'c. i T.7 T-efr-✓C'cC e. 'Hofe°r�e-t�
Name( Current Mailin Addres�5:
•( ��∎
A4 Telephone
Signature gip
2.2 Authorized Agent: Nelson Shif f lett
Valley Home Improvement, Inc. P.O. Box 60627, Florence, MA 01062
Name(Print) Current Mailing Address:
77, /* 584-7522 ___ ____-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item 1 Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building op (a) Building Permit Fee I (o,C;--
2. Electrical (b) Estimated Total Cost of
dye, 1 Construction from (6)
3. Plumbing / Co d Building Permit Fee
4. Mechanical(HVAC) o4.->-b,3
5. Fire Protection $P// J
6. Total = (1 + 2 + 3 + 4 + 5) d,`� Check Number 3/ tQ
This Section For Official Use Only
Building Permit Number: Date Issued: �I
.i`
Signature: — ---..__
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1206
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 62 GILRAIN TER
MAP 29 PARCEL 059 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3 \ -6 1 .3 11 1 S c`
Fee Paid ) t
Typeof Construction: REMODEL KITCHEN&REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing t klik
Accessory Structure n G
Building Plans Included: a t!
Owner/Statement or License 060300 Cl 10 ii .)11
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORM PRESENTED:
roved 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
D- "o .y
00,
Signa - . :midi I 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.
62 GILRAIN TER BP-2013-1206
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-059 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-2013-1206
Project# JS-2013-001978
Est. Cost: $27500.00
Fee: $165.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq.ft.): 20995.92 Owner: BELMONT JOSEPH&ABBY SARITA GIBER BELMONT
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 62 GILRAIN TER
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:6/17/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & REPLACEMENT
WINDOWS - need header sizing before rough
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 6/17/2013 0:00:00 $165.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner