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29-370 (5) 37 AUSTIN CIR BP-2016-1475 GIS#: COMMONWEALTH OF MASSACHUSETTS yMap:Block:29.370 CITY OF NORTHAMPTON at:-001 PERSONS CONTRAL ZING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodsrove BUILDING PERMIT Permit# BP-2016-1475 Project# JS-2016-002528 Est.Cost: Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: ]const.Class; Contractor: License: Use Group: RICHARD SCOTT 83108 loot Sizetsa.It): 13111.56 Owner: MA'TCHETT JACOUELINFK ZO Applicant: RICHARD SCOTT AT: 37 AUSTIN C1R AovlicantAddress: Phone: Insurance: 20 BULLARD AVE (413)478-6306 HOLYOKEMA01040 ISSUED ON:643/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: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 tt Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:/._/67 g Ofe THIS PERMIT MAY BE REVOKE Y E an TY Lt NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE AT N or '/ ,r Certificate of Occupancy , denature: �"�a- IYT.VLot / FeeType: Date Paid: Amount: Building 6/I3/2016 0:00:00 $4000 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner City of Northampton Massachusetts e.`;' Ill A q rjt Main s. tit W 9 DEPARTMENT OF BUILDING INSPECTIONS lM 212 Street • Municipal Building y Northampton, !N 01060 -1 s y P° _. 2S7 l' YU — 91aa - 43b j JUN I O GL OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION jJ, 00 FOR W D,COAL,PELLET,CORN.STRAW OR SIMILAR STOVES,OR FIREPLACES Check# w`i/q5- Please fill in all appropriate information 1. Name of Applicant: i r1 l F r fl (---14' 14' @ r 7 _ Address: riu5 i 1 A Ci jj . _Telephone: `j 2 () r-7 g 7 2. Owner of Property: nn A P Address: S A i44 Telephone 3. Status of Applicant: 1,'" Owner Contractor 4. Type or Brand of Stove : n V JE n a Pc (= 5. Estimated Cost '/OL) If applicant is not the rhomeowner:: Contractor name Rt c-L "^,C G S © S Construction Supervisors License Number -6c1::=. 1Expiration Date c; j '�> Home Improvement Contractor Registration Number J 4 6 Expiration Date_ All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 6. Certification: I hearby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: _ \ APPLICANT'S SIGNATURE V /W`DATE: VA HOMEOWNER'S SIGNATURE \ . _ _ ex y 4111111 APPROVED DATE: BUILDING OFFICIAL The Commonwealth of Massachusetts n w,-- Department of Industrial Accidents faa i Office of Investigations e =�»t1 E r4 — tre 600 Washington Street Boston,MA 02111 ;e4-1.' www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organiation/lndividual): Richard Scott Address: 20 Bullard Avenue City/State/Zip: Holyoke, MA 01040 Phone #: (413) 533-6340 Are you an employer? Check the appropriate box: Type of project (required): L❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.fl I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance., 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.D Electrical repairs or additions 3.11I I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§E4), and we have no employees. [No workers' 13.D Other J O a- comp. insurance required.] / 11 S j A LL- "Any appbcant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers`comppolicy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: ( us') it1. 1 (t c t City/State/Zip: / 6 Q2e n e tt o ( (}h a, 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 fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify�underthe,pains and penalties of perjury that the information provided above is true and correct. Signature: g12 ( ts i st Date: 6- ( -/g J Phone#: y/ t/ ry 7r� 63ob 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 6. Other Contact Person: Phone#: