30A-051 The Commonwealth of Massachusetts
• Department of Industrial Accidents
• a r' Office of Investigations
maw 600 Washington Street
=9 Boston, MA 02111
www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
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. ❑ I am a general contractor and I 6. 1 New construction
employees (full and /or part - time).' have hired the sub - contractors
IF 1 am a sole proprietor or partner -.
listed on the attached sheet. t 7 . I 1 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. 1 1 Building addition
No workers' insurance 5. ❑ We are a corporation and its
[ comp. 10.n Electrical repairs or additions
required.] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL 11.7_ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 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.
*Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
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.
Signature: S ^a" ( - 1 Date: mac ' ' 7 1 ?-c)
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
•
Massachusetts
'6, "` h
A
k DEPARTMENT OF BUILDING INSPECTIONS ;
212 Main Street • Municipal Building
Northampton, MA 01060
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 # �l
,(� PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS l� 7
1. Name of Applicant: Se-^" c^- L
Address: b •\ Telephone: �v��S�S- Fs \U
2. Owner of Property: Sc vv
Address: So-vv w._ Telephone:
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: :CC ,' \ 40
Contractor's Name: "-
Contractor's Address:
Contractor's Phone:
Construction Supervisor's License Number: Expiration Date:
Home Improvement Contractor Registration Number: Expiration Date:
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 -C.A 3 APPLICANT'S SIGNATURE S L J`■G^^
DATE: °"" \ 21 "3 HOMEOWNER'S SIGNATURE Sc- "-""`.
APPROVED
DATE: BUILDING OFFICIAL
64 LIBERTY ST BP- 2013 -0706
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A - 051 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 # B P- 2013 -0706
Project # JS- 2013- 001168
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13808.52 Owner: MANDEL SANDRA
Zoning: URB(100)/ Applicant: MANDEL SANDRA
AT: 64 LIBERTY ST
Applicant Address: Phone: Insurance:
64 LIBERTY ST (413) 585 -8240 0
FLORENCEMA01062 ISSUED ON:1/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL JOTUL 602 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 1/18/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner