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12C-004 (3) The Commonwealth ofMassachusetts Department of Industrial Accidents = —►_ Office of Investigations E _ ;�; _ 600 Washington Street ��` _ y 'ran= Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): R UL A- Address: — 2., 0 2 0 L L City /State/Zip: j S b Phone. #: y/ ,c 6, Are you an employer? Check the appropriate box: Type of project (required): 4. 9 I am a general contractor and I 1.n I am a employer with e loyees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ( am a sole proprietor or partner- listed on the attached sheet. 7. D Remodeling ship and have no employees Theme sub contractors have 8. [] Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. # 9. ❑ Building addition required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3. ❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no f employees. [No workers' 13.0 Other 5D t comp. insurance required.] 1 Y\ '-fit- '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: 2 ' k ` 13 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 pa' s and penalties ofperjury that the information provided above is true and correct. Signature: SZ)V— 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 #: :/ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Su ervisor (CSL) .. , a g—/Y`) � R I c L ei R' b 1 `'� License ) Number Expiration Date Name of CSL- Holder 2 Q ULL ` pi 4e (- , T ) © List CSL Type (see below) Address / • Type Description AN . A le A ti Unrestricted (up to 35,000 Cu. FL) R Restricted 1 &2 Family Dwelling Signature r IS 6 L s 1 1 z) M Masonry Only J RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regi /4 a ed CM Pt vement Contra for (HIC) b Sco rr / 6 1 HIC Company Name or HIC Registrant Name Registration Number - 2_6 A d R u-L, -rt .0 -V F1b yzie. 6 y 6 Expiration Date Signa ure Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) 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 building permit. Signed Affidavit Attached? Yes 13' No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 1, , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Si: ed under the .ains and . -nalties of Lail, NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" The Commonwealth of Massachusetts 01 ; � Board of Building Regulations and Standards FOR "� Cv;E a State Building Code, 780 CMR, 7' edition MUNICIPALITY Qi►i g USE T -7 Revised January 2013 1,2008 o� PERMIT PPLICATION FOR SOLID FUEL BURNING APPLIANCE NORT r Signature: Building Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION 1_I Property dr N 1.2 Assessors Map & Parcel Numbers i I Vo ce A `-- 1.1a is this an accepted street? yes v no Map Number Parcel Number 13 Zoning Information: ' 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq R) Frontage (ft) 1.5 Building Setbacks (1» Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private ❑ Zone: _ Outside Flood Zon Municipal ❑ On site disposal system 0 Check if yes❑ s7' SECTION 2: PROPERTY OWNERSHIP Owner' of R • • - t► 2 . It. t. 0 s'i'V.t- Al2..SAt "( b i d-(t (Print) AlkiMiga Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check a It that apply) New Construction ❑ Existing Building 0 Owner- Occupied ❑ I Repairs(s) ❑ ! Alteration(s) ❑ ` Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units . I Other ❑ Specify: Brief Description of Proposed Wore / Y S [J,) a ‘D i) Q Y T ul Pr ace- tJJ 1 1+ V t-Kl i / I • • SECTION 4: ESTIMATED CONSTRUCTION COSTS item Estimated Costs: Official Use O (Labor and Materials) Only 1. Building S I. Building Permit Fee: $ Indicate how fee is determined: 1 Electrical S 0 Standard City/Town Application Fee 0 Total Project Cost (Item 6) x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) $ List 5. Mechanical (Fire Suppression) Total All F �jj • Check No. 0 heck Amou f Cash Amount 6. Total Project Cost of I V '' El Paid in Full 0 Outstand Balance Due: 47 NORTH FARMS RD BP- 2013 -0794 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C - 004 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 -0794 Project # JS- 2013 - 001358 Est. Cost: $2100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD SCOTT 83108 Lot Size(sq. ft.): 32234.40 Owner: MACDONALD BETSY P TRUSTEE Zoning: RR(100)/WSP(100)/ Applicant: RICHARD SCOTT AT: 47 NORTH FARMS RD Applicant Address: Phone: Insurance: 20 BULLARD AVE (413) 533 -6340 HOLYOKEMA01040 ISSUED ON:3/1/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL QUADFIRE MILLENIUM 4100 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 3/1/2013 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner