44-092 (2) Tlie Coinmonwealilt of Massachusetts
Department of Industrial Accidents
y Office of Investigations
600 Washington Street
Boston,Mass. 02111
www massgoti/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information t Please Print Legibly
Name(Business/Organization/Individual): '�
Address: / /6 (� )—-tCR_r,4 e
City/State/Zip:&F&T 3 C- 1*Of4 Phone#: 44 1 's - Z.3 3-0- 2
Are you an employer?Check the appropriate box: j Type of project(required):
1.X I am an employer with 4. 1 am a General contractor and I 6. _New construction
employees(foil and/or part time). have hired the sub-contractors 1 7. E Remodeling
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees Thee sub-contractors have 8. D Demolition
working for me in any capacity. Cs'T iovees and have workers'
[No workers, comp.insurance zx-mp.insurance. � 9• Building addition
required] 5._: 'VVe are a corporation and its 10. D Electrical repairs or additions
3. G I am a homeowner doing all work ot�?cers have exercised their 11. Ei Plumbing repairs or additions
myself [No workers'comp. 'inht of exemption perm XIGL
insurance required]t c_ 152,§ 1(4),and we have no 12. 0 Roof repairs
employees. [no workers'
13.,f Other
comp. insurance required.] i _
°
*Any applicant that checks box 41 must also fill out the steel=?n below showing-their workers*compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
+Contactors that check this box must attach au 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.
I air an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
information. /1 _ � -7
Insurance Company Name: //1
'
Policy#or Self-ins.Lic.#: WtkV c� J ;`s Expiration Date: z�i
Job Site Address: _ Civy.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?iii . Section 25a of MGL 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
$250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I rho herby cert under the p qum and penalties of perjury that the information provided above is true and correct.
Signature: _ Date: t
Print Girt G' � +° Phone ... f 0 9`16
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 Heath 2. Building Department 3.City/To-*N-n Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#•
City of Northampton
`u i[� °� Massachusetts
i— a y
a I DWAP T OF BUILDING INSPECTIONS y
JEt' •• 5201
4 212 } Street • Municipal Building �kh
orthampton, MA 01060
Electric, Piurr;oir;c-��;�iiicns
NciihaT;; nn, N',A l.'�;.%�
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#,�,,
PLEASE TYPE OR PRINT ALL INFORMATION
r
1. Name ofApplicant:�i LY t'q& h ,1)n .t'u1 //C r
Address: 9YA FLO /y _ Telephone: �/A 6(6? �7��
(I
s
2. Owner of Property: {C
Address: Telephone: S
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: 6 f 1 R M r'T J AQC 9J 1 LR L�1A I —?e I'e-I f ALC/17—
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 a to to the best
of my knowledge.
-A6 DATE: 1 APPLICANT'S SIGNATURE i
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
942 FLORENCE RD BP-2015-0259
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44-092 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2015-0259
Project# JS-2015-000494
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: FIRESIDE DESIGNS 99194
Lot Size(sq. ft.): 31276.08 Owner: DOUVILLE MARTHA J&RICHARD L JR
zoniny,: Applicant: DOUVILLE MARTHA J & RICHARD L JR
AT: 942 FLORENCE RD
Applicant Address: Phone: Insurance:
942 FLORENCE RD WC
FLORENCEMA01062 ISSUED ON.91812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL HARMAN ACCENTRA52i PELLET
INSERT
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 9/8/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner