38B-181 (6) BP-2023-1626
17 FORT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-181-001 CITY OF NORTHAMPTON
Permit: Solid Fuel
Appliance
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1626 PERMISSION IS HEREBY GRANTED TO:
Project# WOOD STOVE 2023 Contractor: License:
Est. Cost:
Const.Class: Exp.Date:
Use Group: Owner: SCOTIA MACGILLIVRAY,
Lot Size (sq.ft.)
Zoning: URB Applicant: SCOTIA MACGILLIVRAY,
Applicant Address Phone: Insurance:
890 38TH A SPC19
SANTA CRUZ, CA 95062
ISSUED ON: 11/17/2023
TO PERFORM THE FOLLOWING WORK:
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
"9 clp
II
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of North t
1�- -TM ` ECGIV `,,::?. s
'� Massachusetts , if
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1`( ;,, ., DEPARTMENT OF BUILDING IN ECT ONS4O V 1 6 :i.:
°71`N1 s k 212 Main Street • Municipal ui1•:nq2�� �� ` Northampton, MA O10 0s14iDEPTOF eUILDINC INSPEC ►�$ I NORTHAMPTON MA 010030
APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION 160
Property Information
Owners Name: StrO41'. Mkc '; //i v-ra I
Address: I 9- roe --- Sf. , /.1I ,1, has Sty a Id 0
(No.) (Street Address)
Phone: 1 1 3V lokell: Email: 1�o-E 020000 t%tc' n'ta;I,co ei
Owners Signature: ,,�` o�'Cl�� r�;� � l Date: �DV, I;1 a( A-3
Contractor's Information (If Applicable)
Name: Phone:
Construction Supervisor's License #: Expiration:
Home Impr. Contractor License #: Expiration:
Stove Information
Type of Fuel (check all that apply): Wood i/ Pellet Coal
Location: Ki i k-C(t e n Freestanding ,- Insert
Manufacturer: v 1t e(L 1 tt)(tert t1 Model: r 4 e t3a(2-f--
----___-__-_-_____-----_FOR BUILDING DEPARTMENT USE ONLY------------__----_-_--
Permit# Date Applied: Total all Fees: S 4/10
Building Official: /Evho 6Z s Date Issued: I I- II-Z0Z.5
(Print) yi
Signature of Building Official:
i
rrn Gl/ / Set 14b4-A 0 0 0 0 VI 04 M A li I . Cep vtl
The Commonwealth of Massachusetts
„r
Department of Industrial Accidents
i 1 Congress Street,Suite 100
t Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): cee--l`a Alf (./1/Vert t{
Address: I .1- t't1L+ 54, /
1 l 1 otone
'/ //`/City/State/Zip: �Q 2-1'G�trI f l m0S #: �3 �` �'"�` ��
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑ ew construction
2. I am a sole proprietor or partnership and have no employees working for me in g
❑ 8. Remodetina
any eapacity.[No workers'comp.insurance required.]
ram✓-i/ 9. ❑Demolition
3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.D Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.DROOf repairs
These sub-contractors have employees and have workers'comp.insurance.: �J
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�ther �'QL'QnIJ (,e9�
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 6"T�-1/2-
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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'comp.policy 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.Lic.#: Expiration Date:
Job Site Address: City/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 under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi under the pains and en I 'es of perjury that the information provided above is true and correct.
Sicnature: C �A �
,lie( Date: l]/10? g0,1,3
Phone#:
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#:
City of Northampton
r:4 °y Massachusetts et''•
Is »'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal BuildingJ a
Northampton, MA 01060 s y1
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
S (� 6.1l d�log 115�3
i, / .(insert full legal name), born — (insert
month, day,year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1,2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision Iicense and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
IA
Signed under the pains and penalties of perjury on this Sunday of heA.._ , 20
14#
(Signature)