Loading...
32A-058 (10) ¢(NAMPJ, z0 Y 0 a Lzfir of 'Nar#Ijamptall a , e �asaarEirrsrtts- ;Z1 m DEPARTMENT OF BUILDD�,,C; INSPECTIO�INS 212 Alain Street ' Municipal Building Northampton, Mass. 01060 'v WORKER'S COMPENSATION VgSURANCE AFFIDAVIT I, Nelson Shifflett, Valley Home Improvement, Inc . (licenseripe,mittee) with a principal place of business/residence at: 340 Riverside Dr. , Northampton, MA, 01060 (phone,) 584-7522 do hereby certiry, udder the pair L-id penalties of penury, (g) I am an employer providing the following worker's compensation coverage for my employees wor'ting on this job: Acadia Insurance Co. 0109302-11 2/1/06 (Insunanc-- Company) (Policy?tu=ber) (Expiration Daze) ( ) i am a sole proprietor, geaeral contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: Nae of Con=,-tor) (Insu-ance Conipany?olicy Nulni cr) t��t iration Date) m trac (Name of Contraor) ;lnstlran(-- ComoauyiPolicy Number) (Ixpiration Date) --i;hame of Contmctor) -- (Iasurance Companylpoucy?iuulb<:) (Expir.tion Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (auach udd?jon l shoot if necessary to include i fazuaftoa paminiug w till oDatmttors) ( ) I am a sole proprietor and have no one worlang for me. ( ) I am a home owner performing all the work myself. NOM please be aware this while homeowaen who empicy pe som to do mai�consaucdon or repair work on a dwelling of not mote thaw throe traits is which the homoownrr r=d=or an the gvaads appurt ,Ant thereto are oot gmaally coandered to be employers under the work=`s compasatioa Act(GLl52.ss 1(5)),application by a homcowarr far a liceme or permit may m idcnoe the legal Raba of an employer under the Workeez Compemation Act. 1 understand tbat a copy of this csatemeat may be for%w%i*d to the Depwtrrat of Ind L..e isl A=doa&Offroc of irrrrrance for the coverage ve ificatioo sad that Lihtre to seen=coverage under soction 25A of MGL 152 can lead to t'Je imposition of cr=izW pemltiea ooesixing of a fine of up to SI.500.00 and/or imp;iso�of up to one yew and civil penalties in the form of a Stop Work Order and a Lae of S 100.00 a dly agniast tnc. /7 Signed _��ti2.y of���p� rM..dgmtaoas,l use only Si ed this I mit Numbcr ' Lot# /V /-5oll S`i`// G,IZ % ' a , SECTION 8 -CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicable Name of License Holder : Ne130n Shiff1 t 060300 Valley Home Improvement, Inc. License Number 340 Riverside Drive Northam on, MA O'I n60 9/22/06 ---- Address Expiration Date 584-7522 Signature f Telephone l 9 Registered Home Improvement Contractor: Not Applicable ❑ Valle.} Home Impro-vement" Inc_ 105543 _ Company Name Registration Number 340 Riverside Drive _7L17/A 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 affidav't will result in the denial of the issuance of the building permit. � I Signed Affidavit Attached Yes....... 20 No...... ❑ i 11. - Home Owner Exemption The current exemption for"homeowners"vvas extended to include Owner-occupied Dwellings of one(1) or tnvo(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 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 titassachusetts General Laws Annotated. Homeowner Signature . 'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding j ] Other [ ] t Brief Description of Proposed Work: V'A0 �ui0 BOCA+k rc>�wl Alteration of existing bedroom Yes 11� No Adding new bedroom Yes No Attached Narrative _: Renovating unfinished basement Yes No Plans Attached Roll _ - Sheet. sa. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms i c. Is there a garage attached? d. Proposed Square footage of new construction. _ Dimensions e. Number of stories? f. Method of heating? _ Fireplaces or 'Noodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? ype of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade i k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT C'ug -76 ✓n m T Z as Owner of the subject property f hereby authorize Nelson Shifflett, Valley Home Improvement, Inc, _ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Da e 1, Nelson Shifflett Valley Home IMprovement, Inc- as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Nelson Shifflett Print Name s 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. re N there any proposed changes to or additions of signs intended for the property ?YES _ No IF YES, describe size, type and location: r i Department"use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit v6 212 Main Street Sewer/Septic Availabllity " >= Room 100 Water/Well Availability- Wl ha pion, MA 01060 Two Sets of Structural Plans phone 413--x°87.1240 Fax 413-587.1272 Plot/Site Ptans� = r Other S r APPLICA'T'ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 2 -SITE INFORMATION 1.1 Property Address: This section to be completed by office -- v� Map Lot Unit Zone Overlay District C1 � Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: j 01716 S/ — Name(Print) ` Curren':Mailing Address: T-- Te!ephone Signature 2.2 Authorized Agent: Nelson Shifflett Valley Home Improvement. Inc. P.O. Box 60627, Florence, ?4A 01062 Name(Print) Current Mailing Address J1 6111-41W _584-7522 Signature Teie_phone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 2� Q 0 o (a) Building Permit Fee 2. Electrical 1 1500 (b) Estimated Total Cost of Construction from 6 3. Plumbing 3 5 0 Q Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) '2�, C? t� Check Number 6J`"� '" This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 50 UNION ST BP-2006-0757 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:32A-058 CITY OF NORTHAMPTON Lot: -029 Permit: Buildinq Category: BUILDING PERMIT Permit# BP-2006-0757 Project# JS-2006-1162 Est. Cost: $25000.00 Fee: $125.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Valley Home Improvement, Inc 105543 Lot Size(sg.ft.): 0.00 Owner: AGNA GWEN&THOMAS MARANTZ Zoning.URC Applicant: Valley Home Improvement, Inc AT: 50 UNION ST Applicant Address: Phone: Insurance: P O Box 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:113012006 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL 2 BATHROOMS 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 Sienature: FeeType• Date Paid: Amount: Building 1/30/2006 0:00:00 $125.0020594 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo