29-388 (3) i ne uommonweatin of Massachusetts ri uit rurm
Department of Industrial Accidents
Office of Investigations
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/Organization/individual):
Olde Hadleigh Hearth&Horne Center,Inc.
Address:119 Willimansett Street
City/State/Zip: South Hadley, MA 01075 Phone #:413/538-9845
Are you an employer? Check the appropriate box: Type of project(required):
1. ❑ I am a employer with 8 4. R I am a general contractor and 1 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 8. ❑ Demolition
working or me in an capacity. employees and have workers'
g y � 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. officers have exercised their 11. Plumbing repairs or additions
❑ 1 am a homeowner doing all work right of exemption per MGL ❑ g p
myself. [No workers comp. g p p 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no Install wood stove
employees. [No workers' 13.0 Other
comp. insurance required.]
A ny applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy information.
I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
nployees. If the sub-amtractors have employees,they must provide their workers'comp.policy number.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
!f6rmation.
isurance Company Name:Travelers Insurance Home Improvement Contractor's Liscense#148198
olicy # or Self-ins. Lic. 0EU1351971381 Expiration Date:7/12/20114
)b Site Address:_ City/State/Zip:
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ai 1 ure to secure coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
do hereby ce!:qQ under the aims and enalties V&rjua that the in ormation provided above is true and correct.
nature: Date 8/10/2013
tone #:538-9845 CS SL#9878
Offeial use only. Do not write in this area, to be completed by city or town offrcia[
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
6. Other
Contact Person: Phone#•
City of Northampton
SAS S/ 1
Massachusetts
G
DEPARTMENT OF BUILDING INSPECTIONS S
212 Main Street • Municipal Building v OD
k - Northampton, MA 01060
4�s w
GG
! L N
i
SI GLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
_ -I
Permit Fee: $25.00 Check# L 2—
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: -Tea 0,-t`e
Address: 5L 90 OU Telephone: 1��'� �- ( S 3
2. Owner of Property: ' ` C
Address: Telephone:
3. Status of Applicant: V Owner Contractor
4. Type or Brand of Stove: ���� V�' _ "`�l 't-4 6,
If applicant is not the homeowner:
Construction Supervisor's License Number Expiration Date
Home Improvement Contractor Registration Number Expiration Date
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowle ge.
Z% ( APPLICANT' NAT
DATE: APPLICANT'S SIGNATURE
DATE: 2111 ��( HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
52 BROOKWOOD DR BP-2014-0924
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 29-388 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-2014-0924
Project# JS-2014-001594
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15725.16 Owner: HALE TED O&REBECCA J OTIS
Zoning: Applicant: HALE TED O & REBECCA J OTIS
AT: 52 BROOKWOOD DR
Applicant Address: Phone: Insurance:
52 BROOKWOOD DR
FLORENCEMA01062 ISSUED ON:31312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VERMONT CASTINGS INTREPID II
WOODSTOVE
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 Siiinature:
FeeType: Date Paid: Amount:
Building 3/3/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner