42-081 The ColanwnWAM of Massacblaetts
Deparhneid of Indrrsl"Accidents
Qf 9ce of INY0*4dons
600 Wasltington Stmt
Boston,MA 42111
wwlr.MAMgov1WU
Workers'Compensation Insurance Affidavit:BuLdwa/Contractors/Elect icians/Ptumbers
Anplicant Information Please Print Lw"bly
Name(Huss msorganizetiowindivwum): F(� Gt1G,S a�' e ��n L,-r--
Address: �'6& t �� Roc-&-- � S %o l
City/StateJZip: bolo �/T Phoned#: 0 d-a5y
Are you an employer?Ckeek*be appropriate box: Ty pc of project(required):
1.IN I am a employer with [S 4. I am a general contractor and I
employees(full and/or part-time).' have hired the sub-canUa�tars 6. ❑New construction
2.❑ I am a sole proprietor or partner, listed an the anaebed sbeet. 7. 0 Remodeling
ship and have no employees Thew a6-contractors have 8. n Demolition
working for me in any capacity. employees std have workers' 9. F3 Building addition
ad
[No workers'camp.inuartce comp. •t
require&] S. ❑ We are a carposatim and its 10.[]Electrical repairs or additions
3.111 am a homeowner doing all worst officers have exercised tbsir 11.0 Plumbing repairs or additions
Myself.[No Workers'comp. risht of amption per Mme' 12.11 Rod repairs
insurance reiuiredLl t C. I 52.41(4�and we have no
employers.[No wards' 13.
insuranceXquiMO
•Aar d M dwGks bone tir Eno M20 Su out.doe Iipa beta r showis$their watmu'compawshm pdiey M&MAMR-
t Howwwom who submit this dlUw t iodkwas Ow nor doing ad wort did thud bier ovum*saeaswoct mmt sibout saw affidavit uKkaW*sV*
toma.caods that dw*this ion snort tmadmd m aaditiord aura d or ias tie same oEtboauboosbaors and shoe whrdwr a not timid saber bm
=Wbyom If&wb4oaksam hoe employees,they must prairie*wr welters'oomp.ply dwoia-
Cgatart eaaployes rise dlr lrtat+ iisg atwr�eri'eau+ t�iete issrrausese fa►�r evtlP�1' Below Jr die polky and job s!u
anfonrstiort.
Inmeasee Company Name:
Policy#or Self-ins Liz.Ij t&X-'A o a-)8--j'R —t Jam' Expiration Irate: 1-5
'
Job Site Address: I _& -[z n&> 0ty/St"zip: 1"" .1c7 0 ( loo*
AttvA a copy of the workan'compensation poky dedWratJOB page(Aowiag the policy number and expiration date).
Fame to secure coverage as requirod udder Socxiae 25A of MGL Q 152 can lad to iba imposition of criminal penalties of a
fine up to S1,5Ot1.00=&d/or one-year hmpaisetamtnst,as wall as civil DwAkies in the Form of a STOP WORK ORDFR and a fine
of up to$250.00 a day against the violator. Be advised that a dopy of this statement may be forwarded to the Office of
Investigations of due AIA for insurance coverage verification.
I de ka4y t tatldrr sail of teat ors brfan atedt pror�ed absd+e b tired sxd correct
- i aa1Lt
ne#:
�ICjq/an DO AOf tl►/It!Its Oh iris,JO be tdntpldat 69 cify of lOWtt OffIciaL
City or Town: Petvtit/Ueeafe#
Issuing Authority(eirek one):
1.Board atHaalt!► 2.Brig Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Otber
Contact Penton: Pboee#:
I
City of Northampton
Massachusetts
Ljj
p I
�> 1 DWAR"dHNr OF Brrsnrac 2NSP=TTatvs 7
Uji 1 212 Main Strut • Municipal Building
r q N Northampton, HIL 01060
W Z
O
S GLE 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
1. Name of Applicant N
Address: G+.T Telephone:�010;L-ad-k
2. Owner of Property:_ i C-0
Address: t ja C� Whone:
3. Status of Applicant____Owner Contractor
4. Type or Brand of Stove:_QUA T I u to,
If applicant is not the homeowner:
Construction Supervisor's License Number tt��� Expiration Date 60&/1
Home Improvement Contractor Registration Number (009 Expiration Date
All Applicants must complete a Workers Conmpensadon Insurance Affidavit before we can Issue a permit
5. Certification:I hereby certify that the information contained erein is t e and accurate to the best
of my knowledge. &AWeE
DATE: G I APPLICANT'S SIGNATURE l
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
1226 GLENDALE RD BP-2015-0604
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 42-081 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-2015-0604
Project# JS-2015-001159
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. fil 54014.40 Owner: HOLT BRIGITTE M
Zoning: Applicant: HOLT BRIGITTE M
AT. 126 GLENDALE RD
Applicant Address: Phone: Insurance:
126 GLENDALE RD
FLORENCEMA01062 ISSUED ON.11126/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.QUADRAFIRE 2100 MILLENIUM 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 SiEnature:
FeeType: Date Paid: Amount:
Building 11/26/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner