16C-025 The Conunonwealth of Massachusetts L Pant Form I
7. " : i Department of Industrial Accidents
1 _
Office of Investigations
! 1 1 Congress Street, Suite 100
",. Boston, MA 02114 -2017
v
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business/ Organization /Individual): James , t • --- SQ�
-
Address: 62 St nnnw,P c- S C dC X t6 is
City /State /Zip: v q-c , cl \A CACO 5 Phone #: Ct 75 - 5450 - � /7'3-
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub- eontaetas 6. ❑ New construction
2g I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in capacity. employees and have workers'
g any p tY insurance.:
5. 9. ❑ Building addition
[No workers' coo p comp. insurance T
required.] ❑ `�� e are a corporation and its 10 ❑Electrical repairs or additions
3. ❑ 1 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 J
employees. [No workers' 13(lther 5'
I 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 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.
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:
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 hereb certi _under the pains and penalties qjerjury that the information provided above is true and correct
Si. natur/ ��" - _ _ _ Da e 5 1 ..2 I
Phone #: Ci7 f• O '77,2
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 #: r
Ci y Of Northampton
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Q-or RE ''°°` Massachusetts �� '�
t Cep 0 zo •' -AR s.+ OF BUILDING INSPECTIONS S '
s"' ` '! 2 - • - = B l a ipal Building J .�A
Tof IAA 01060 'PSI, c
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�PNO4tTHAMF ; ON,
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check P d 9/
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant � okt,....e. g . ti"\ 41\,..S ---4- // CDo X 2f68
Address: C,7-- 5Uwwv Qc 5'N rre, 644 ctQ25Telephone: Q7$ 5 6-0 a 77a
2. Owner of Property: L i' Moc(■ ,v■
Address: o[ 0 (' v\q St c
. �', \CL , OA ( ta 6 I 7 5 / : -� ) (
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: F' \arid €c l J cn p 5'�0ue-
If applicant is not the homeowner:
Construction Supervisor's License Number 10 5 50 7 Expiration Date 1 / 1CAPO t 61
Home Improvement Contractor Registration Number 1 e( 3q Expiration Date (,/.2 3 /,-Qo 1 3
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: 1 hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: 5 / 13 / P APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
209 SPRING ST BP- 2012 -0976
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C - 025 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 -0976
Project # JS- 2012- 001694
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES WALLING 105507
Lot Size(sq. ft.): 33236.28 Owner: MORRISON LISA A
Zoning: URA(92)/WSP(91)/WP(54)/ Applicant: JAMES WALLING
AT: 209 SPRING ST
Applicant Address: Phone: Insurance:
62 SUMMER ST (978) 880 -8772
BARREMA01005 ISSUED ON ::5/10/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ENGLANDER 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 5/10/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner