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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
Nelson A. Shifflett / Valley Home Improvement, Inc.
(licensuJpermittee)
with a principal place of business/residence at:
320 Riverside Drive Northampton, MA 01060 (phone#) (413) 584-7522
(str--_t/ci ty/sty/::i p)
do hereby certify, under the pains and penalties of perjury, that:
M I am an employer providing the following worker's compensation coverage for my
employees worlang on this iob:
Travelers Insurance Co. UB888139983 2/1/00
(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/Pohcy 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 iacluda information pertaining to all coa ra ton)
( ) 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 etnplay percoas to do maintensacq construction or repair wort;on a dwelling of
not more than throe units in which the bomeowoer resides or on the grourxrs NTudeaaoi therdo an no(gencrally ooaridercd to be
employers under the worker's c ompens4on Act(GL152,ss l(5)�application by a homeowner for a lice=or permit may evideaoe the
legal clan,of an employer under the Worker's Compomation Act
I undesstaad that a copy of this rutemmi may be forwarded to the Depautmm2 of Industrial Aed Office of Insurance for the
coverage verification and thin failure to ware covcrngo under section 25A of MOL 152 can lad to the imposdion of criminal penalties
000siv*of a fine of up to S 1,500.00 and/or imprisoaaiart of up to one year and civil pcn&Wcs in the form of a Stop Work Order and a
rum of 5100.00 a day again,me.
Signed this L3 day of //�--'''' L,i 1999 For —may
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' THE COMMONWEALTH OF MASSACHUSETTS FF.
BOARD OF HEALTH
Toe JQJ OF or nm1,n1y,(_)
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Punnit,u Construct ( ) Repair (�) l Ipgmde t ) Abandon ( ) -XI Complete Sys,cm ❑Individual Components
14m 900cl RPM:-'W 23a
�mnn 1 ( cr',Ng
1 r -e
.) Addrcti m h 01'0(co
3 Ml,*v i 355_&' vgncr Nnmc do
111 -t Add—,
S .,JS.a s( 5�s�- &o
Telephone a Telephone ft
Type of Building: S1 tio�2 Q�/Yn Lot Size Sy.feet
Dwelling—No.of Bedroo s // Garbage Grinder ( )
Other—Type of Building No.of persons 8 Showers ( ), Cafeteria ( )
Other fixtures �/
Design Flow(min.re wired)IWO gpd Calculated design How gpd Design flow provided�gpd
Plan: Date �"c�7- Number of sheets Revision Date
Title ��l._)ooe I SIJOSa/ Scu54eln,- -e.Da.LA- — 8ay-er
Description of Soil(,) G See K 'nr+S
Soil Evaluator Form No. Name of Soil Evaluator ct Date of Evaluation 7 aa-9 9
13
DESCR PTION OF REPAIRS OR ALTERATIONS I A>>'�h
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
4 Signed 6-4-4"m Date — 0 q 9
Inspections (j
FORM 1 -APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. CO NWEA THOFMA
MASSACHUSETTS FEE
OARD OF HEALTH
CERTIFIC E OF COMPLIANCE
Description of Work: ❑ Individual Component(s) gComplete System
The undersigned hereby certify at t e Se wa e D'spo al System;Constructed( ),Repaired( ).Upgraded( ).Abandoned( )
bv: _l�l//f at_��
has been installed in accordance w' th ovisions of 310 CMR 15.00(Title 5) and the approved design tans/as-built
plans relating to app' at o No. 7� dated 1 5!7 Approved Design Flow s/ (gpd)
Installer
Designer: Inspector / Date ��
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3-CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
-------------------- -----------------------------------------------
No. - THE COMMONWEALTH OF MASSACHUSETTS FFF lT
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Re air Upgrade ( ) Abandon ( ) an individual sewage
disposal system at [;�[7 �h� c! q as described
in the application for Disposal System Con truction Permit No. ���J/ dated
Provided: Construction shall be completed within three years of the date of this per tocUitioi ube met.
Date / Board of Health N� �it3r--
FORM 2- DSCP DEP APPROVED FORM 5/96
FORM 1255(REV 5/96) (_1 I I W HOBBSB WARREN M PUBLISHERS-BOSTON
11-30-99
Tony:
As you can see from application,this house currently has three bedrooms, and we'll be
adding another room/bath to be used as a bedroom. An existing 1s`floor bedroom is to be
converted to an office to be used by ServiceNet staff.
The attached septic system plan allows for three bedrooms.
Do you want us to remove closet, or closet door on 1'floor?
Nelson .
10. Do any signs exist on the property? YES NO
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DOE TO
LACK OF INFORMATION.
This columm to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
V
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&pai,ed parking)
# pf -Parking spaces
#
of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
�* is true and accurate to the best of my knowledge.
DATE: �1-�1j (� y APPLICANT's SIGNATURE �^
NOTE:lssumnoe of a zoning permit does not relieve an appli rs burden to oomply wlth-4&ll
zoning requirements and obtain all required permits from th card of Health, Conservation
Commission, Department of publio Works and other applicable permit granting authorities.
FILE #
, .
�
uv / ^
��"�y \
File No' '
�� ^� ���� (.§10 . 2)
=�����.� ����^�� =� � ���==��=^,
pIF,ASE TYPE OR PRINT ALL -INFORMATION
1. Name of Applicant:
Addreso mepnune:
~-
2. Owner fP rty
Address: ze4-/imopnuno: —'
3. Status ofApplicant: Owner Contract Purchaser Lessee
G/ Other(explain): 6
4. Job i / -'
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FIL IN BY THE BUILDING DEPARTMENT)
. Existing Use Structure[Property
6. Description of Proposed Use8Vork/,r jeotlOocupudon: (Jso addibono\ sheets ifnecasoury):
Aclol Ae!;&m a oL- /%6�i), 959 az
L A'ouq mn) 44WI4 /47/.Jv 40/ /P
7. Attached Plans: _j���~_ Skatch Plan 3ito Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has Special Permit/Variance/Finding ever been issued for/on the site?
N DON'T KNOW YE3 |F YES,date issued:
_________
IF YES: Was the permit recorded ot the Registry ofDeeds?
NO DON'T KNOW YE
IF YES: enter Book Page and/or Document
Q. Does the site contain a brook, body of water urwetlands? N{} DON'T KNOW YES________
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobo obtained Obtained .date issued:
(FORM CONTINUES DN OTHER SIDE)
t t
File#BP-2000-0551
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 (413)584-7522
PROPERTY LOCATION 130 TURKEY HILL RD
MAP 34 PARCEL 009 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid �/ �� D
T eof Construction: CONSTRUCT 2ND FLR BEDROOM/BATH OVER EXISTING CHANGE 1 ST FLR
BEDROOM TO OFFICE FOR GROUP HOME
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 F 9LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
pproved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Conservatio mmission
1.2 199
Signature of Building 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.
130 TURKEY HILL RD BP-2000-0551
GIS#: COMMONWEALTH OF MASSACHUSETTS
r'!��4.Block- 34-009 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate&ory: alteration-addition BUILDING PERMIT
Permit# BP-2000-0551
Project# JS-2000-0972
Est. Cost:$34000.00
Fee:$170.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor. I License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sq. ft.): 39988.08 Owner: ServiceNet
Zoning: RR Applicant: Valley Home Improvement, Inc
AT.- 130 TURKEY HILL RD
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers Compensation
FLORENCE 01062 ISSUED ON:1212199 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2ND FLR BEDROOM/BATH OVER
EXISTING, CHANGE 1 ST FLR BEDROOM TO OFFICE FOR GROUP HOME
OST THIS CARD SO IT IS VISIBLE FROM THE STREET
nspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amnv!nt-
Building 12/2/99 0:00:00 $170.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo