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10B-083 i i i i i 12/15/2015 08:55 4135650820 VALLEYHOME PAGE 04/04 «..j 14.J9 I41in�r12r1 NTON BLD DEPT PAGE: 02/02 Properly Address: -- �Q�� Leeds Contractor j J Name: Address: RIvKs i of e Dr. City, State: rI �C e mA. Q 1 b6'�- Phone; 4113 - 58Y 75,;��` Property Owner 1qo-a3 W0'rces+e-r' Name: -- - - Address,. 8aQ '93 City, Mate: MA- 01c), •,3 jpkrA erY ,fsk-t --(contractor)attest and afFirm that the building !intend to insuiate does not have ary open air(knob and tube)wiring in the spaces to be insulated and that I have provided ft propeq owner with a copy of this affidavit. Contractor signature Date i i i ne c tlfffJEnionweaun gj1wassac6a-seiTs Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston MA 02111 _ -F f www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �� � Please Print Legibly Name (Business/Organization/Individual): 1,If C�L:o Address: '-�C, �``�V���C:�� �� City/State/Zip: ' `Ofj�abf, 0 Phone##: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. E] I am a general contractor and I 5. E]New construction employees (full and/or part-time). have hired the sub-contractors 2-El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. E]Demolition working for me in.any capacity. employees and have workers'comp. F-1 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] c. 152, §1(4), and we have no 1 employees. [No workers' 13Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance,jbr my employees. Below is the policy and job site iirf0r•inafl n. insurance Company Name: 1ff Policy#or Self-ins. Lic.#: ��J�J0 02-P Expiration Date: Job Site Address:,)o)8,)3•q Ma i n 5+ City/State/Zip:Leet MP cw53 Attach a copy of the workers' compeusat lion PoUcy deelaratlon gage(gigawfAg the poUcy number and expiradon date). Failure to secure coverage as required under Section 25A of 1\ GL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance,coverage vpiification. do hereby certify e:a Y tfre pains a fa�pen�lti�e perjury that the inforrnadonr provided above is trae and correct Signature: Offlcial use only. Do not wHie in this area, to be cOft-Pleted�by city or te�wr' o��r:cia1 � ii Cif Qr�Lerwn: — �erreTflLECeaFe f! 1.Beard of Health 2.HuPldiug Department s. e.i�/To�wn Clerk 4._Elect cal In:.c,�eeto� S.t�tu�L,���Inspector 6. Other � Contact Person: Phone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) CS 1087 W Jcb) D2xner6 k 1 License Number Expiration Date Name of CS -Holder 11 � ,3q,D Fiver 5 cke- Flccence, List CSL Type(see below) Addr (�� (A6k Tye Description �/ 1 U Unrestricted(up to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwelling y"� 3 cr-e� 75a;L M Mason Only !`�� RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5. R ist red Home ImprovementContr ctor(HIC) 1b5 czl 3 j J C Com y Name rHIC Registr ame Registration Number 3x7 V v RCP MAO �- 7 Ada lw 4/3-5 7� .xpiration Date Sin tune Telephone SECTION 6:WORKERS'COMPENSATION IN URANCE AFFIDAVIT(MG.L.c.152,§ 25C(6)) Workers Compensation Insurance affidavit must be complet d and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the b 'lding permit. -Si ned-Affidavit Attached? - -Yes :.'....... - -No 13 SECTION 7a:OWNER'AUTHORIZATION TO BE CO PLETED WHEN OWNER'S AGENT 1NT OR CONTRACTOR APPLIES FO BUILDING PERMIT 1, WC3�L�S '� as Owner of the subject property hereby authorize PX ' ally Home- roYUnetrfi to act on my behalf,in all matters relative to work authorized by this building permit applicatio . S tore of Owner Date SECTION 7b:OWNEW OR AUTH ZED AGENT DECLARATION I, Il e l le _ ntli,0710, Owner or Authorized Agent hereby declare that the statements and information on a foregoing app tcati n are true and accurate,to the best of my knowledge and behalf. Print Name L -1-7 6 4)h k�Sig azure of Owner or Au rized Agent Date (Signed under the pains and penalties of a"u ) NOTE 1. An Owner who obtains a building permit to do his/her owp work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIq)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other i portant information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in1780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Foal Project Cost" i i S pE Gu; C, --s MAEo ABuilding Regula ions and Standards FOR tis.c; r"oP�NAM� assachusetts State Building Code,780 CMR,7`h edition MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Propert A d ess: 1.2 Assessors Map&Parcel Numbers aa�-a 4 ainst ie�, MA oto53 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: - Zoning District Proposed Use I.ot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required [____Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flo Z ne? Municipa�On site disposal system ❑ Check if ye SECTION 2: PROPERTY OWNERSHIPt 2.1 Owners o Record: A 0,Y IA er'C eX aa8-,:,i_3q l kin'sf, M A ©i c6 3 Name(P' t) Address for Service: 4 pied see bcx; vC �Raae-A"l- qJ5-5% /aaS" Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: ih5 Q 1a 10r) rief Desc ':)tion of Proposed Work': 0 lr IL emen " C r ilY3v I v 1 � �z SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:` 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $p?7b0,QC7 11 Paid in Full ❑Outstanding Balance Due: File# BP-2016-0790 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 228 -230 MAIN ST MAP IOB PARCEL 083 001 ZONE URB(148)/WP(148) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid e Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108772 3 sets of Plans;Plot Plan THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Demolition Delay Sig ure 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. 228-230 MAIN ST BP-2016-0790 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 1013 -083 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-2016-0790 Project# JS-2016-001332 Est. Cost: $2700.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 108772 Lot Size(sq. ft.): 9844.56 Owner: WORCESTER MARY Zoning: URB(148)/WP(148)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 228 - 230 MAIN ST Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.•1211512015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 12/15/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner