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STORAGE
GIPE MASTER BEDROOM
221 CHESTNUT ST
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TIME AND MATERIAL ROT
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - REPAIR OF ROOF OVERHANG _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _'
SIX PANEL HARDBOARD EVES ACCESS
SMOOTH SOLID CORE DOOR
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UP
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GIPS MASTER BEDROOM
ii 221 CHESTNUT ST
FLORENCE. MA
EXISTING CONDITIONS
EXISTING DORMER
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imuivl_rrvi
Page 1
O�St fpT0
8 � � ,oai i[ZS8Ch1t5tlt5 --
Gitly of
m DEPARTMENT OF BUILDD TG INSPECTIONS '
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COAITENSATION MURANCE AFFIDAVIT
Nelson Shifflett, Valley Home Improvement, Inc.
(Uccnse&pernuttee)
with a principal place of business/residence at:
340 Riverside Dr. , Northampton,MA 01060 (phone,) 584-7522
do hereby certify, under the palms and penalt es of Der;ury, that..
(X} I am an employer providing the following worIkeris compensation coverage for my
employees working on this job:
Acadia Insurance Co . 0109302-10 _ 2/1/05
(Insumnce Company) (Policy Number) (Ex=tfon Daze)
( ) 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 CompanyPolicy Numbr) (Expiration Date)
(Name of Contractor) (Insurance CompanytPoiicy NUMnbe-) (Expiration Date)
(Name of Contractor) (Insure-- Company/Policy Nnrri> r) , \piration Date)
(Name of Contractor) (Insuran=Company/Policy Number) (Expiration Date)
(attach additioml shoo ifneoeaary to mchWe information pertaining to ail ooatractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plea=be aw=e that whilo homeowners who employ pea om to do m micnance,conszn=oa or rcpair work on a dwelling of
not mac thaw throe units is whicb the bomcowner resides or ou the Vvjnde apptutcna thereto are oot SaXraky aoasiderzd to be
employers under the worker's aompczssation Act(GL152,ss 1(5)),appacation by a homeowm far a Gccom or paint may evidence the
legal aztua of an employer under the work es C.ompemaiion Aci
I undmund tbat a oopy of tb a statcmmt may be forwarded to the Depwuncoi of Industrial A=&a&Office of Imunwm for the
coverage verification mad that failure to scathe oovemp under section 25A of MGL 152 can lead to the imposR'son of aimioal penalties
000sisCng of a fine of up to S1,500.00 and/or imprisorarl>a2 of up to one year and civil peaatdcz is the form of a Stop Wort Ord=and a
Sao of S100.00 a day againd mG
Signed this For drp�use onty
SECTION 8 -CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shif flett _ 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive Northampton, MA ningn 9/22/06
Address Expiration Date
584-7522
Signature Telephone
9 Ragjstered Home Improvement Contractor: . Not Applicable ❑
Valley Home Improvement, Tnc 105543
Company Name Registration Number
340 Riverside Drive __ 7/17106
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....... ® No...... ❑
11._- Home. Owner Exemption
Flic current exemption for"homeo vners"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 be
responsible for all such work performed under the buildinz 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
t
'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[ ] Other [ ]
Brief Description of Proposed Work: '411" d f *,I
Alteration of existing bedroom 1! Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll _ - Sheet.—I
6a. If New house and or addition to existingfiousing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
Is there a ara e attached? 1
g g
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? f
f. Method of heating? AIKA 7� Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Y36 Mascheck Energy Compliance form attached?
Type of construction & G4 'h
i. Is construction within 100 ft. of wetlands? Yes � No. Is construction within 100 yr. floodplain Yes No
1. Depth of basement or cellar floor below finished grade
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
as Owner of the subject property
hereby authorize Nelson Shifflett, Valley Home Improvement Inc to act on
my a" in all matters relative to gauth rized by this building permit application.
t
gnatur of Owner Date
I, 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
Section 4.
A-LL LNFORMATION MIDST 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 n
Side L: R: L: R: %I
Rear
Building Height (�
Bldg. Square Footage C I %
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? N04-*--- 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 y
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:
s '
Department use only
f Northampton Status of
1 "1 I ding Department Curb Cut%bay it ..
2 �2 Main Street Sewer/Septa ailab7tty�
2004
oom 100 Y,� - r/Well
NOV
No ton, MA 01060
- p T:a etsa
phone 4_ 587 1240 Fax 413-587-1272
Plot/Site P
Other Spec
APPLICATION TO CONSTRUCT,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: z
Name Print) Current Mailing Address:
32.5`Zl
!! Telephone
Signature a
22 ori—dAgent: Nelso Shifflett
Valley Home Improvement, Inc P.O. Box 60627, Florence, KA 01062
Name(Print) Current Mailing Address:
Mki*z6_1 584-7522
Signs ure Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I ,
File#BP-2005-0568
APPLICANT/CONTACT PERSON Valley Home Improvement,Inc
ADDRESS/PHONE P O Box 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 221 CHESTNUT ST
MAP 17A PARCEL 139 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: ADD 14'DORMER TO ENLARGE BEDRM&ADD BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildina 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 ATION PRESENTED:
_iZApproved 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 Co on
O
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
H
221 CHESTNUT ST BP-2005-0568
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17A- 139 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0568
Project# JS-2005-0748
Est. Cost: $32500.00
Fee: $162.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 060300
Lot Size(sa.ft.): 17859.60 Owner: GIPE JAMES W&KIMBERLY HICKS
zoning;URA Applicant: Valley Home Improvement, Inc
AT. 221 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:11 115104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 14' DORMER TO ENLARGE BEDRM & ADD
BATH
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: Receipt No: Date Paid: Check No: Amount:
Building 11/15/04 0:00:00 18818 $162.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo