23D-089 (2) 04�tiAMPJO
e' $ Grif r ,af 'Ward amptun x
9 �IassAChnsctfa
DEPARTMENT OF BUILDr NG I.NSPEMONS
212 Main Street ' Municipal Building '
O,,y Sv,yi
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
11114 (phone#) -52Y-/5-Z2—
' (s> -,--Ucity!s'-tP 2io5
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 worlang 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 additiocal sleet if neoasary to include infocmarion pertaining to all ooahnctm)
( ) 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 paw=to do maht=ax,constn"on or rtpair work on a dwelling of
not more than three uaiis is which the homeowndr reside of on the groin appurtea thereto are not generally 000sidered to be
employers undtt the worke's camp=utiom Act(GLI52_=1(5))�application by a homeowner for a license or p.-raa may--n-d==the
legal status of as employer under the Worker's Qompomdion Act.
I uada:tsad that a copy oftbis statement may be forwarded to the Dep uu=cd ofIndantrial Attddeoss'offioe of Icsumoce for the
coverage verification and that failure to s==coverage under section 2 5 A of MGL 152 can lead to tha imposition of mammal pecnaltieies
oomisting of a fine of up to$1,500.00 andlor mmprison of up to one year and civil p=LWes in the form of a Stop Work Order and a
faro of 5100.00 a day against me.
Signed ✓ _ aay of ` �r f r'�'" I� J For dT=t=nW use
oalY
Permit Number
iv4ap# Lot W
ignat ure of LicaEseel#ernaiitee
'����,'s�,7 3 t � �;: s`3s at.R.3t�'�e �E ✓ .. ., y.,
C n�truc'frvn '�utwra Ism, 1 S4 ' F amik
G: : CSFA-060300
FLORENCE NIA--4l1 tlb2�- �
t JJy1 s
Coin m"oanor 09/2212014
OffiCe Of C 011Surner Affairs and Business Reaulation
10 Park Plaza - SUite 5 170
Boston, 'Massachusetts 02116
Home Improvement Contractor Registration
Re
gisiraton: 10554
Type Private Corporation
Expiration: 7117/2014 Tr# 226093
VALLEY HOME IMPROVEMENT INC.
Nelsen Shifflett
P.O. Box 60627
FLORENCE, MA 01062
Update Address and return cart#. Mark reason for change.
Address Renewal Fraployinent Lost Card
^
-
SECTION 8-CONSTRUCTION SERVICES
.1 Licensed Constrq Not Applicable 0
Name of License Itolder : Nelson S f 060300
Valley Home Improvement, Inc. License Number
340 Riverside
Address Expiration Date
Telephone
Company Name Registration Number
Address Expiration Date
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submi-fted with this application. Failure to provide this affidavit
wilt result in the denial of the issuance of the building permit.
11. , Home,Owner Exenlintion
The current exemption for"horneowners' was extended minclude pied [one(l) ortwo(2) families
and m allow such homeowner mcrim individual for hire who does not possess alicense,
as sutwirvisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of :pcanu(x)whoovmupmzc!o[|uodonwhichhclisbcrroidcxor(ntendomrcside,vowhic6/boo:
is,or is intended to be, a one or two family dwelling,attached or detached structures acce%sory to such use and/or farni
—ructmrrcs. A person who corstructs more than one home in a two-year neriod shall not be considered a homeowner.
Such"horneowner"shall submit to the Building Official.on a form acceptable to the Building Official,that he"She shall be
responsible for all such work pet-formed under the building permit.
As acting Construction Superviso yoorpresence mothe job site will 6e required from time oo time,during and upon
completion of the work for which this permit ixissued.
Also he advised that with reference coChapter 1521 (Workers' Compensation) and Chapter 15� (Liability uf Employers tn
Employees for injuries not resulting in Death)ofthe Massachusetts General Luno Annotated, you mov he liable h»rpo,son(o)
you hire\o perform work for you under this permit.
The Undersioned"homeowner"certifies and assumes responsibility for compliance wilb the State Buildirl�cndc.C\� oy
yJurtbmnp/on Ordinances, State and Local Zuoino Laws and State n[Massachusetts General Laws Annotated.
'"�`TI P! Vii. •�ESE;FttP�`IfJtSi dF PE�€11�C1SEi;3�`.QRK_E�:ht��"�„�at6 �.t?��krl
Ata;w ller�.e ! Addition S Replacement Windows Xteration(s) f.� � Rooting r
Or Coors
Accessory Bldg. 2 Demolitior.-7j � New Stares Decks ) Sidir,� ; � X
r..
� : - s cr
It:,c°t Trsul InI L U� alI use +C, 6ln• /� E
u&t#ve,rs rte+p dkik star'�xa � �k�erl of c ti3ca f S wjc�llul 1`/
� c C'tC. vitr,k'It •" _. __.....�.. � i„kY I .� :-fS a Pt .ft":r „KS:�Cr$t"';"� ,._ ���'.�
6a- If New house and or addition to existing,housing, complete the following
7 -ar"1 ',itl"f'�,>
;# F"'�:,. �� r, ,. _. .,,... " � ".s�-;r^. .' t'Y+�+.� ._.�r�Rw...�f�.'r�7 it.._�ss�•E. �a�. ._ .___....� _... .
I
VC. 1
�•...tca[k4. .:..�«"".� Eia _ ' :...+ _•�"{ r,,.uv ri ;?i .;l I C.. "or T ;.`.tzrl'cl'..'
I
, 1��.;'t°�lr,,HE:i�'r �rrfEts t �C., ( �t s.a< ;:�o$ ��....�__ _ ��`• ...w_.�._.. '`!,�_ �; •a:�t't5,tr`:�LI �r� �w ,f err i(}t, ,�t °I_,.r.E.�l.� .a ____._....� __.`_7�`. t
i
� _..f .'� ,':£ a.a`. 3,�°-rs4 '. r ti�f41,,�s t'���t ���ICs�v s�rrl��.� F„t•t��
6
1" y,
�ka"+f Y
k SECTION 7a • OWNER AUTHORIZATION ,TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
` m
.Nelson Shifflett, .,Valley_ Home_ Improvement,_ Inc,
"r � �:rr .It c.^. .• ! •ra!f� ., �. ::I. .� ff., � .r ��tzt"��'t:'r..C: :xi !'l¢5 L..t ,. r�, .7r";'r r, .:)f'sis,..tr:.`ro
47 4r40`t Y .r'.lrr
Nelsen 5�i�ff ar r,�Y31ey� te Improacetiaen .
�9.. E�'i' d..0 1.rf' �: .'. �,�SIL',rr'p"Ct"� .,Fl; t!"ff.)rr `E"C�'v!! 1�'� �fl!. rJ4• " !r '1_� .?i :C.. 0°:� .. �.t�, `i�� t �_ ^ti,
t p .•:I K t+ -nr hnccr,
Nelson Shi f f 1 e.t.t.__
I :!`:q1 M1. ^:•w :.�-r lire(.a,
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 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:
Department use Y"wt
City of Northampton Status of Perhiit
------ Building Department Curb Cut/Dnveway Permlt��
212 Main Street Sewer/Septld vailability
r Room 100 Water/well Availability
Northampton, MA 01060 Two Sets of StructuralPlans
i DEC t C L013
phone 13-587-1240 Fax 413-587-1272 PIot/Site Plans .
i----_ _— Other'Specrfy
APPLICATJONJOMt STRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2:-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
J() CC Q5 ea7-f f 5 td'-j riles
Name( rint) Currgn't Mailing Address:
qso
Telephone
Signa a �!
2. Authorized Agent:
N C91sc 5 i 'ie ct. w Home- 41 Taiti �t 3W) -River s i de- 'fir: Fk ej-) e A
Name(Print) Current Mailing Address:
y13--5�3L!-'-7 5
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �7C (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 7(� C~ Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0735
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 15 WARNER ST
MAP 23D PARCEL 089 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT_APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC&WALL INSULATION
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
INF�MATION 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
De o ' 'on Delay
Signature of Building fficial 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.
15 WARNER ST BP-2014-0735
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-089 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-2014-0735
Project# JS-2014-001249
Est. Cost: $4700.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq_ft.): 12763.08 Owner: ROSENFELD EMILY A&JOYCE ROSENFELD
Zoning:URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 15 WARNER ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:1211812013 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & WALL INSULATION
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 12/18/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner