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44-079 (2) The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigadons 600 Washington Street Boston,Mass 02111 www.mtas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers Appnt Information .. Please Print Legibly Name(Basinesslorganization/Individual): Address: 1769 City/State/Zip:&EET MA Phone#: 4z 13—73 a'D Are you an employer?Check the appropriate bog: Type of project(required): Q6 I am an employer with 4.0`I am a nal contractor and I 6.0 New construction employees(full-and/or part time).* have hired the sub-contractors 7. 0 Remodeling 2. 0 I am a sole proprietor or partner. listed eat attached sheet. ship and hwm no employees These ctors have &. 0 Demolition working for me in any capacity. employs and have workers' 9.0 Building addition (No workers'comp_insurance cep_ii4prance.T required] 5.0 we arse ae oration and its 10. 0 Electrical repairs or additions 3. 0 lam a howtowner doing all work oifims have a eised their 11. 0 Plumbing repairs or additions myself (No wk's'comp. right of ern perm MGL insurance required]t c.152,§1(4k and we have no 12.0 Roof repairs ce;s'fm workers' 13.)d Other GOMP- Imo-] *Any applicant tbat checksboL#1 mast also 5H out the section below shawing'fLar workers'compensation policy Worumfioa tuomeewnen who submitthkaffidavit indicating dwyme doing A werk and then Lire outside contractors mast submit a new 2M2vit iadicatiog such $Contattors that check tWbo�c mast attach an addilional sheosbowing the same of the sub-contractors and state whether or not those entities have employees. If the scoaa s®�,gnLr=they most their werkera'comp.acuity number. I wn all employer tkat apmvz&V wD7*emI mrgm=aam w' we fbr my�1� is file poUcy aNljjob She tnfo m-M� '�v Insurance Company Name: s dA., Policy#or Self-ins.Lic.# W Expiration Date r 1 Job Site Address: ChYfi4BbMffAp: Attach a copy of the workers'.cempensatioa gooey der iaratiou gage(showing the poky number and expiration(date). Failure to secure coverage as required under 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 tsvil penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day against violator.Be advised that a copy ofthis statement maybe'forwarded to the Office of investigations of the DIA for coverage verification. I do herby cer .►ender the d penalties of perjury that the inform n vide above is true and correct: Si abate: Date: Print Name: Phone Official use only Do not write in this area to be completed by city or town official City or Town: Permitllicense#: Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• qC�® DATE(MMDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 7/28/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Nan Usher NAME. Nancy Martin J Clayton Insurance Agency PHONE (413)536-0804 FAX (413)534-7874 1649 Northampton Street E-MAIL P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERB:Safety Insurance Company 014 P & P Marketing, Inc. DBA Fireside Designs INSURER C:Technology Insurance Company 1769 Riverdale Street INSURER D: INSURER E: West Springfield MA 01089 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1472200803 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL UBR POLICY NUMBER MM ML LTR DDIIYYYY MDONYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,0001 A CLAIMS-MADE a OCCUR A 19961F /7/2015 /7/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident P BODILY INJURY(Per person) $ B ANY AUTO 100,00 ALL OWNED X AUTOS HDULED 210727 /17/2014 /17/2015 BODILY INJURY(Per accident) $ 300,000 X HIRED AUTOS X NON-OWNED & RENEWAL /17/2015 /17/2016 PBOPERdTYDAMAGE $ 100,000 AUTOS PIP-Basic $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN J.1ML ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBEREXCLUDED? NIA C3065543 /31/2014 /31/2015 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under RENEWAL /31/2015 /31/2016 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500r000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Fireside Designs ACCORDANCE WITH THE POLICY PROVISIONS. 1769 Riverdale Street West Springfield, MA 01089 AUTHORIZED REPRESENTATIVE i Daniel Sullivan/MEG ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. Mrtild5t6d with pdfFactory tria'I`'v 66OR yowyy:pW1`n1My.'rtW' -` °" /x Office of Consumer Affairs & Busfi ess Regulation ME IMPROVEMENT CONTRACTOR egistration: 158891 Type: xpiration: 3113/2016 Private Corporatic. P&P MARKETING dba FIRESIDE DESIGNS JEAN PELOQUIN 1769 RIVERDALE ST WESTSPRINGFIELD, MA 01089 Undersecretary Massachusetts - Departrrent of Public -Safety Boa-,,d of Budding Regulattons and S-17atidards Construction Supervisor Spedaio License- CSSIL-MIN JEAN C PELOQUJN S 93 CARVER sTREEr, GRAMY MA Of 033 f TWT)I S S 0 vj yr r�vr. vrrwr� vvrr Massachusetts i ' DEPARTMENT OF BUILDING INSPECTIONS AUG /� 212 Ma"n Street • Municipal Building + UU ✓ Northampton, MA 01060 :,-�eaiions Electric, Pius 'u'r'? MP, �1uG0 Ncrth�a7�{-� SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS � y,9,0-D Permit Fee: $2M Check # PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: -TA M6 Z1-12 A Address: -iL c is , /'7A Telephone: 41 3 5 cO' - 5 3`-2- 2. Owner of Property: ,j Arit:s !9. Zts R jq Address: 23 IA-ii-+N 4:t i='«�zN,mac�, /��+ c,c d �- Telephone: �rj 3 .!;"Z,y y 3-r;t. 3. Status of Applicant: Owner Contractor 4. Type or Brand of Stove: /-/A PZ/-(A Al If applicant is not the homeowner: �r2 Construction Supervisor's License Number / f ` 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 knowledge. ✓ ATE: 3 � ' APPLICANT'S SIGNATURE DATE: HOMEOWNER'S SIGNATURE APPROVED DATE: BUILDING OFFICIAL 22 AUTUMN DR BP-2016-0194 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:44-079 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-2016-0194 Project# JS-2016-000334 Est. Cost: Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FIRESIDE DESIGNS 99194 Lot Size(sq. ft.): 10018.80 Owner: ZERA JAMES A&LINDA R Zoning: Applicant: ZERA JAMES A & LINDA R AT: 22 AUTUMN DR Applicant Address: Phone: Insurance: 22 AUTUMN DR (413) 584-9342 O WC FLORENCEMA01062 ISSUED ON:811812015 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL HARMAN P35i 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 8/18/2015 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner