Loading...
22B-009 The Commonwealth of Massachusetts I Print Form I Department of Industrial Accidents rt Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Leiibly Name (Business /Organization /Individual): / Y1 Address: 9 a. S P 2 L S City /State /Zip: jk a r bCa . Phone #: 1) / 3 5S t3-( F Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 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. ❑ 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 ca employees and have workers' g for me in any capacity. ty 9. ❑ Building addition No workers' comp. insurance comp. insurance. 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0- Other t..t©t) C7o a 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. 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 * s and penalties of perjury that the information provided above is true and correct. Signature: I 7 Dated // /3 Phone #: *'i J 8 7 ' °r 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 #: ro ' _ City of Northampton aYHAM ryV�y; Y ''' 1 LW , Massachusetts `.{ G i s ,� ■ i ��,, 'ECTIONS DEPART NT OF BUILDING INSPECTION 1 'I ,; � ' G 1a 01060 212 Main Street • Municipal Building S , ^D � : , Northampton, MA 01060 s sy,.j\'�� 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 # ,. � PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: r yF a y (0,: rc- i s c� Address: 7 9., S P I t. A, (, S'T Telephone: 4 )/ 3 5 1 a U 2' 2. Owner of Property: ' I ea i'y (J.f f`rc 7 re Address: 9 ' . . 1 , , , ' . f L.21 Ai (-, S. / Telephone: h i 1 3 51 `f 2 g' 3. Status of Applicant: 1/ Owner Contractor 4. Type or Brand of Stove: L1 Fit 0 ,N i r4 .c 1 Ai ( -. S / n/ i - 2.L j 0 TL £A A -LYr1c WO rd ST)L /& If applicant is not the homeowner: Construction Supervisor's License Number /CMG (c c� L�'1 Expiration Date ;"i /mil 0.0 i 4 Home Improvement Contractor Registration Number /37 53 Expiration Date .,/ 9/3.-0i ' f All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 5. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Za2 -29.1f DATE: - i - /:}A) ; 1/ 13 APPLICANT'S SIGNATURE ✓ '� �� ( / r DATE: 5A-A) i 1 / 9.01 HOMEOWNER'S SIGNATURE 4:17 7-(4 °IL) APPROVED DATE: A BUILDING OFFICI L r 92 SPRING ST BP-2013-0697 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B - 009 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- 2013 -0697 Project # JS- 2013- 001153 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 25003.44 Owner: WATROBA MARY Zoning: URA(100) /WSP(100) /WP(9)/ Applicant: WATROBA MARY AT: 92 SPRING ST Applicant Address: Phone: Insurance: 92 SPRING ST (413) 584 -2188 0 FLORENCEMA01062 ISSUED ON:1/11/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VERMONT CASTINGS INTREPID II CATALYTIC 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 1/11/2013 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner