35-199 _ Department of Industrial Accidents
Office of Investigations
Y, I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business' rganization.�Individual): �� ��� � ��PP
Address: ' V&
City/State/Zip: Phone
Are you an employer? Check the appropriate box: Type of project(required):
1JZ" I am a employer with 4. ❑ I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for the in any capacity. employees and have workers'
[No workers' cornp. insurance comp. insurance. 9. ❑ Building addition
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 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL -] Roof repairs
insurance required.] 1 c. 152, §](4), and we have no
q ]
employees. [No workers' 13. Other
comp. insurance required.]
''Any applicant that checks box 41 must also fill out the section belotiv shoving their A+orkers'compensation policy information.
t IlomeoNners who submit this affidavit indicating they are doing all pork and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet sho«ing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees.they must provide thcir workers`comp.policy number.
I anz an emplover that is providing workers'compensation insurance for my employees. Below is the policy and,job site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic. 4: ✓� �`7 7 Expiration Date:
Job Site Address: Z• '" '�� u " City/State/Zip: '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 tine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D1A for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: -- ` __. — �_ - Date:
`Phone 4:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#:
i
iii
a FEB 2 12014 a
I,
ity of Northampton
�>-
�ctlons Ma►saachusetts
>� of Burlonro uvsrPatrays ;
212 Holz Street * Municipal Building Jar
Northampton, DA 01060
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES,OR FIREPLACE INSERTS
Permit Fee: $25.00 Check#_ f8 q
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicaf 7l KLL'N Q 46" _
Address: //Y-y / S 'f lQI-�' Telephone:
J
2. Owner of Property. S5;�� y✓n`�J / .t/1�A
Address: GjLly 17`SS s /{T, b Telephone: aL
3. Status of Applicant i/O,w[ne�r __—Contractor
4. Type or Brand of Stove
N applicant is not the homeowner
os�l
Construction Supervisor's License Number jj Expiration Date (�
Horne improvement Contractor Registration Number /�y�`�Z' Expiration t7a#e 7�z
All Applicants must complete a Workers Coampensadon Insurance Affidavit beform we can issue a permit
S. Cettlftcstion:I hereby certify that the Information contained herein is true and accurate to the best
of my knowledge_
f.
DATE: , '� ��J� APPLICANT'S SIGNATURE
DATE: .�` '��'� HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
I
1144 BURTS PIT RD BP-2014-0898
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 199 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2014-0898
Project# JS-2014-001556
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq.ft.): 11543.40 Owner: O'LEARY STEVEN J&NINA M
Zoning: Applicant: O'LEARY STEVEN J & NINA M
AT. 1144 BURTS PIT RD
Applicant Address: Phone: Insurance:
1144 BURTS PIT RD O 586-9820 O WC
FLORENCEMA01062 ISSUED ON:212112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL HARMAN PELLET STOVE
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 2/21/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner