36-189 (3) • The Commonwealth of Massachusetts
Department of Industrial Accidents
iimoimumarirf
Office of Investigations
mliezra
600 Washington Street
Boston, MA 02111
0" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
/
(4.
/ /
Name (Business /Organization/Individual): ` -
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ( 1 I am a general contractor and I 6. New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub- contractors have 8. 111 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 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, §1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*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 suck
tContractors 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 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 under the pains and penalties of perjury that the information provided above is true and correct
1 Date:
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 #:
MA Construction Supervisor #CS009989 / MA HIC #148198 / CT HIC,556609
Olde Hadleigh • Hearth & Home Center,. Inc.
119 Wililmansett Street, South Hadley, MA 01075 Tel (413) 538.9845, FAX (413) 538.8753
WOOD STOVE INSTALLATION CHECKLIST
Permit
A building permit Is required for the fnsta1)ation of any solid fuel burning
appliance. The building permit and installation inspection are limited to the
stove Installation and' not to the stove construction,
Stove.
A) TYpc /cpolant circulating __•
8) Manufacturer 'test label
. (after July T 1979 only)
Name /Model No, Collar size ___,,
Nimenslons /Height Length Width
Chimney
A) New Exl'sting
8) Size (flue area)
C) Ocher appliances attached to Flue (Number and flue size)
0) Metal (Manufacturer - and type)
E) Masonry /Lined
Unlined Flue liner _
- (type t manufacturer)
r) Height (refe'r to diagrams) cap Ni o•.
lo ' 1L .;
_ f .�% —r— / `\\' tow Sv (Z
9. % .
• (F— o /.ri+ ,
`"i � — • u.n l .r•
III r 604 HEARTH
— r . __ .. .:... .
CHIMNEY HEIGHT
A) Materials• •
Hearth (min, 1 lir, fl re resistance B) Sub -floor cons.tructic+n
C) Minimum dimensions (refer to diagram
Clearances .and "Walt Protection(
see stove 1nstal1Rt ion clearances chart) . 4<,. A) Type of wall protection provided —_...
::)7,„,. 8) Clearances (refer to dl•agrams) •
___-_K ...
'..
4.,..4.,.,
.'
1. ___ 1 ,
• ,
•
FIREPLACE CORNER WALL/CENTER
■
.9. Print Form
,;� The Commonwealth of Massachusetts
Department of Industrial Accidents
, � ,+ .I Office of Investigations
%,, '+ 7 ; 1 Congress Street, Suite 100
r '`
x ; Boston, MA 02114 -2017
4 F 5' ww w.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Olde Hadleigh Hearth & Home Center, Inc.
Address: 119 Willimansett Street
City /State /Zip: South Hadley, MA 01075 Phone #: 413/538 -9845
Are you an employer? Check the appropriate box: Type of project (required):
1. 171 I am a employer with 8 4. (1 I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. (l Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
for me in any capacity. employees and have workers'
working Y P ty. 9. 0 Building addition
$
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t. c. 152, §1(4), and we have no Install wo od stove
employees. [No workers' 13. rA Other —
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.
CContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
mployees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
f am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
insurance Company Name: Travelers Insurance Home Improvement Contractor's License # 148198
Policy # or Self -ins. Lic. #: IEUB5197681 Expiration Date: 7/12/2012
Job Site Address: U �(P i�r fi s / f • A City /State /Zip: r/0/ ?/2/' P 1 »'/ 6/Z6
A.ttach 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
3f 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.
f do hereby certi# under the pains nd penalties of perjury that the information provided above is true and correct.
z
Signature: . .. Date; 11/11/2011
�
?hone #: 538 -9845 CS SL #98784
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: �J� Not Applicable fi❑
,p
Name of License Holder : /fit t. ' 9 / (/ 9
License Number
i44 J , ` ? 571 ' '" . 4alkyl 0#9. eAvs- ) /' / 3
Address Expiration Date
yt3 -.,5 -3 9f '/5'"
Signature Telephone
e „., ,,.. \_.
9 Registered iiom ml provemen C:i 'tractor,. " , : . 7 ' 4r :, ; Not Applicable ❑
Company Name Registration Number
/ M/ /� '/ 7 s / 7 1 Si. 9 , 13
Address Expiration Date
/4d/'y , 'F 9 .e 7
Telephonef0 '74 7 S
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L e. §25C(6)) ; 'i
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ing permit.
Signed Affidavit Attached Yes No ❑
1 1:.:- iom . + xemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner: Person (s) who own 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 homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, Sta and Loca onin aws and State of Massachusetts General Laws Annotated.
R
,. Homeowner Signature Z L
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check alt "applicable) „
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors D
Accessory Bldg. n Demolition ❑ New Signs [0] Decks [[ Siding [0] Other []
rief D cripf n gf,Pro o ed ` '--
dvork: //7_57 // /4/1 544, aL'CPrr� A j ` �lf/ /O/j'Z & .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a " If -_NewWhouse,.andoradd eez stingliousrngaamp eteA
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION -TOPE COMPLETED WHEN , ,. .
OWNERS AGENT"OR CONTRACTORAPPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, --D D. -' LID -t `f A a 6 N) S (E C,- 1--- as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury .
DON) PrLb — A St\AeON -= 5I E. 6-e L..
Pri t Name
„ec7-_„,19.(ii \ , . , ,,4--)1S '
Signature of Owner /Agent J )( 9
Date
•
J
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b
Existing Proposed Required by'Z'oning
This column to be filled in by i
Building Department
Lot Size
Frontage
Setbacks Front I j I w
Side L:' R: L:I I R:` 4 ' i
Rear
Building Height 1 / i F
Bldg. Square Footage l ! i % ? 1 i
Open Space Footage %
(Lot area minus bldg & paved =
parking)
I i I I
# of Parking Spaces `
Fill: i
(volume & Location) i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book I
1 Page; 3 and /or Document tti F
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
I
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. WIII the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. � p- DepartmeMt„use only F * „ ,,
City of Northampton status of Pe it I
Building Department C urb , ut/ e m _ � � �
e yai ilit ��
NOV 2 9 2011 212 Main Street Sewer
Room 100 Water/Well Aiabil
p�r oF�m o irrawsPECUON N rthampton, MA 01060 4w4� ets of a trpctural Pt g a � '' "
ON - 587 -1240 Fax 413- 587 -1272 P �� la wry
. �
(7 r Sped " � ' ' = . ,,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE,INFORMATION ' -
This section to be completed by office
1.1 Property Address: � - : � � , , � . �
(,� f v ' S� T D `Ma Lot r - Un
- x t '�? w. ".+ h ! , ' g '' ' 1' _
P I (j v. e N c e m �' �� t) Z ane Overla Drstnct
:E1m,St.�b . " '" " CB "Drstnct _.- ``
S 2 - PR OPERTY OWNERSHIP /AUTHORIZED AGENT `
2.1 Owner of Record: t-
D 0� t, i � S I C c e, \ S 4 I',./ - t3 i y I, - ? 1—
ame i 1 c� V tC-
( r] Current
C. cling Address: 4-1('N N 0 �0 t
.` "
�J �.,�_� Telephone
Signature I �
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
S . TION 3 - ESTIMATED CONSTRUCTION COSTS
em Estimated Cost (Dollars) to be Official Use Only . `, . -
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from. (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ,
6. Total = (1 + 2 + 3 + 4 + 5) „2-.t9�' , rf Check Number
This Section' For Official Use O
D ate
Building Permit Number: . Issued:
Signature.
Building Commissioner /Inspector of Buildings Date
846 BURTS PIT RD BP- 2012 -0530
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 189 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- 2012 -0530
Project # JS- 2012- 000880
Est. Cost: $5200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): 31232.52 Owner: SIEGEL, DONALD S & SHARON G
Zoning: SR(100) //WP Applicant: SIEGEL, DONALD S & SHARON G
AT: 846 BURTS PIT RD
Applicant Address: Phone: Insurance:
846 BURTS PIT RD (413) 341 -3421 0 WC
FLORENCEMA01062 ISSUED ON:11/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 Signature:
FeeType: Date Paid: Amount:
Building 11/29/2011 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner