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03-026 The Commonwealth of Massachusetts. Print Form Department of Industrial Accidents Office of Investigations 4 r 1 Congress Street, Suite 100 Boston, MA 02114 -2017 www.mass.gov /ilia Vs'o rkers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name( t3usiness Or anization Indiv idual): BERNATDSTON FARMERS SUPPLY Address:43 RIVER STREET C s1ale zi : BERNARDSTON, MA 01337 phone #:413_648 -9311 . Art u on an employer? Check the appropriate box: Type of project (required): I I am a employer \\ ith 1 1 4. ❑ I am a general contractor and I 6. n New construction cmplo■ees (fu ►1 and /or part-timer' have hired the sub - contractors 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling I_. prI skip and have no employees These sub - contractors have g. Demolition orkiag for me in an\ capacit\. employees and have workers q ❑ Building addition j Ate «orkers comp. insurance comp. insurance.: 5. 0 We are a corporation and its 10.1 Electrical repairs or additions '. i g a homeowner doing all work officers have exercised their 1 1._ Plumbing repairs or additions right ght of exemption per MG L myself. [No workers' comp. g p p I 2 Roof repairs murance required.] c. 152, § 1(4), and we have no employees. [No workers 13. ❑ Other comp. insurance required.] _J , ohiic;mt that chccks pox -I must also till out the section belm% showing their workers compen.ati■0 police information. I ionic(no ners vv ho submit this Aidav it indicating the ■ are doing all work and then hire outside contractors must submit a new affidavit indicating such. C ‘s r actor that check this box must attached an additional sheet showing the name of the sub - contractors and state sOhether or not those entities have cmplo) ccs. II the sub - contractors has c emplo ees. thc■ must provide their workers' comp. policy number. 1 aim alt employer that is providing workers' compensation insurance for my employees. Below is the policy and job site ill /0rm atir)11. nsur,n;cc ( ontpa Name: PEERLESS INSURANCE COMPANY or self -ins. 1 le. :WC8165644 Expiration Date: JIoh `ite \ddress: 3' ( a g ofeS it) E AD K., (7) Cit v iStatc /tip: ttach 4t copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Hi! coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of tO 51.500.00 and'or one -year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a tine or up to S250.00 a da■ against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inve- titlations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the in provided above is true and correct. `- L11 - 1;u ui1/4:: Date: 413- 648 -9311 '•'ilo 1L — Official use only. ))o not write in this area, to he completed by city or town official ( i ts or "limn: 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 #: " City of Northampton - 4 S� , ..i '' Massachusetts �w$ - 1 1 A , ' 1 ' DEPARTMENT OF BUILDING INSPECTIONS y, T ' ! ' 21 Main Street • Municipal Building ` �� ' 3! Northampton, MA 01060 Jsth ,, ,. \ 1 ' 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: D oUq/QS L- '6Qhbe _ ( 3 /'14Nt 3 1at.' rAr lur S S Address: 1 /-3 '-. i VCS S - ' Eg► [/ /2 1:.) 57Of�l MP Telephone: 4/3- 0 5/0' - 9 3 i/ 2. Owner of Property: , -//in FL TO Address: 5 C_- / �0/eS m t C3 7 Telephone: y /, Z °/V - 86:� 9 3. Status of Applicant: Owner 1 7-Contractor 4. Type or Brand of Stove: H,4, rf /I tq - /Yl d D EL - X .Y V 7r //El S 10 i C 1,014 5C116 12K - 71rcc- (cFJ1 Vim C h'rnf) -y CL //h ©ulS1 ,bL-` A ix /ci `T' If applicant is not the homeowner: ,` Construction Supervisor's License Number 99 Vo 2 - Expiration Date / - ' 6 `/7 Home Improvement Contractor Registration Number /60V Expiration Date 7-Z9-// 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. �, - -� DATE: /2/7 APPLICANT'S SIGNATURE _. e C _ DATE: HOMEOWNER'S SIGNATUR ��' 1 APPROVED DATE: BUILDING OFFICIAL 583 COLES MEADOW RD BP- 2013 -0689 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 03 - 026 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 Pennit # BP- 2013 -0689 Project # JS- 2013- 001138 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BERNARDSTON FARMERS SUPPLY 99402 Lot Size(sq. ft.): 80019.72 Owner: FLYNN JAMES Zoning: RR(100)/WSP(100)/ Applicant: BERNARDSTON FARMERS SUPPLY AT: 583 COLES MEADOW RD Applicant Address: Phone: Insurance: 43 RIVER ST (413) 648 -9311 () WC BERNARDSTONMA01337 ISSUED ON:1/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL I0\ARMAN XXV PELLET 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 REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 1/7/2013 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner