11A-018 (2) 32 EAST CENTER ST BP-2017-0745
GIS ft: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 11A-018 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeoty:woodstove BUILDING PERMIT
Permit It BP-2017-0745
Project# _ JS-2017-001239
Est. Cost:$2900.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin RICHARD SCO I I 83108
Lot Size(sq. ft.): 21039.48 Qvner: MOORE t„QRA.S GO LORA 1 SANDHUSEN
Zoning: URA(100), Applicant: RICHARD SCO I I
AT: 32 EAST CENTER ST
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413)478-6306Q
HOLYOKEMA01040 ISSUED ON:1212/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RAVELLI WOOD 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# 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 REGUULATIONS.
Certificate of Occupancy signature:
FeeTvpe: Date Paid: Amount:
Building 12/2/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-.Building Commissioner
City of Northampton
Massachusetts
t\ ?. DEPARTMENT212 S OF 9IIZLaxxc al Building
212 Main rthamC • Municipal Building
Northampton, MA 01060
At. ,.t 6
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD,COAL,PELLET,CORN,STRAW OR SIMILAR STOVES,OR FIREPLACES �7ry O
Check# "A 0 J � Yt'
YY D Please fill in allappropriateinformation
1. Name of Applicant : i.. R.- r'{' /"`. �',. y � f 'v) �, r -.
Address: 73 2 r'• fl 3-1- [• L fl 1-C4 S Telephone:
2. Owner of Property: L +T' A 7 IZ D 7+(},S 'E'+'iw
Address: 3 t Z /'!':S i C£ 1 QOL 5 r Telephone: Y7 2S ( j
3, Status of Applicant: `." Owner Contractor
4. Type or Brand of Stove
}_ R Pc
_l V \ ._
S. Estimated Cost U LS
It applicant is not the homeowner:: 141 �� /l ./'J<'(
Contractor nameO ! �G�fff yyy'
f i
Construction Supervisors License Number � ;5 � 'tag gExpiration Date '+ t I
Home Improvement Contractor Registration Number / Y? 0 U J Expiration Date 3- 2-1 g
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
6. Certification: I Nearby certify that the information contained herein is true and accurate to the best of my
knowledge,
III i!'
DATE: i { ' 1 I (1 APPLICANT'S SIGNATURE ' y>� -- akoe. 2
DATE: > I } HOMEOWNER'S SIGNATOR•
APPROVED / -I/y'��> "r���„_�
iii / "/
DATE: ���+�
/O „_ BUILDING OFFI �� •�/
The Commonwealth of Massachusetts
—�— Department of Industrial Accidents
e=Titer--at Office of Investigations
•@ v:4w=_i 600 Washington Street
F,
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Richard Scott
Address: 20 Bullard Avenue
City/State/Zip: Holyoke, MA 01040 Phone #: (413) 533-6340
Are you an employer?Check the appropriate box:
I.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
2. X❑ I 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 for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance4 9. Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their 11
right of exemption per MGL repairs or additions
myself [No workers' comp. g P MGL 12 ❑ Roof repairs
insurance required.] c. 152, §I(4),and we have no 13 ] Other Stove Install
employees. [No workers' _
comp.insurance required.]
*Any applicant 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 sub-contractors have employees,they must provide their workers'comppolicy number.
1 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.Lic.#: Expiration Date: •
,/
lob Site Address: Z / ��i1 I y tel)L Sr City/State/Zip: C[� ed) J
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 be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and r the pays an a allies of perjury that the information provided above is true and correct-
Signature: 11 Date: ///b �
Phone#: (413) 533-6340
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):
I.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: