31B-009 (2) The Commonwealth of Massachusetts ( Print Form I
Department of Industrial Accidents
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1 '� y Office of Investigations
1 ` b y 1 ,i j5 1 Congress Street, Suite 100
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• _� Boston, MA 02114 -2017
�'� f www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
A DBA BERNARDSTON FARMERS SUPPLY
Name ( Business /Organizati on/Individual).
Address:43 RIVER STREET
City /State /Zip:BERNARDSTON, MA 01337 Phone #:413- 648 -9311
Are you an employer? Check the appropriate box: Type of project (required):
1. El I am a employer with 10 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
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 for me in any capacity. employees and have workers'
9. n Building addition
[No workers' comp. insurance comp. insurance.:
required.]
S. ❑ 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 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other
employees. [No workers'
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: PEERLESS INSURANCE
Policy # or Self -ins. Lic. #Y" 8165644 Expiration Date: -1 -13
Job Site Address: / / 6 1 re fPLt i a/ City /State /Zip: Al alb/ a p /tn 0 / 4 6
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 certij under the - I,, d penalties o s er'u that the in ormation provided above is true and correct.
�,,_ ✓ f D ate ' / 7
Signature: -, ,;-,-/
Phone #: t//3 6 y y °V3 /)
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
4 ' C ty of Northampton
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f ' ,,Ate � ' 2 2013 Massachusetts 2, c,� A.
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' I . P OF Bu rL ' S ON S MEET OF BUILDING INSPECTIONS 1111 !!!!
1 NCRTHAM TON Mr, 0' 060 1 Main Street • Municipal Building
Northampton, MA 01060 st h ,n
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 # 011 1/
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: D c = `7 / i - • ` di bC' `—
Address: / /7RRICi'5 -,5' T - +� 1`413/ frVlf) GI 033 Telephone: `// 7/3 a 5' -- 1
2. Owner of Property: /9A/7 ie /1 /"c "X
Address: // 0 e Prz 6,,.3 7 , 6 -c r Si vogrilrimproN Telephone: /S 5 n - C GO-
3. Status of Applicant: Owner :.''
4. Type or Brand of Stove: /% c,/7 5 NL- 3 - /77 °NT - PE - 1 /I. (Alb /WS CRT
If applicant is not the homeowner:
Construction Supervisor's License Number (19 / Expiration Date /--( - /V
Home Improvement Contractor Registration Number /4'PY,5 Expiration Date ' 7_ Z ?../y
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: :.5 - / .V.1 S APPLICANT'S SIGNATURE / b -`..: ` ��'
DATE: c ‘,.... - / 9-1S HOMEOWNER'S SIGNATURE 4 < 9
a .
APPROVED 111
DATE: BUILDING OFFICIAL
110 PROSPECT ST BP- 2013 -0859
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 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 -0859
Project # JS- 2013- 001467
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 8973.36 Owner: FOX ANDREA B
Zoning: URC(100)/ Applicant: BERNARDSTON FARMERS SUPPLY
AT: 110 PROSPECT ST
Applicant Address: Phone: Insurance:
43 RIVER ST (413) 648 -9311 () WC
BERNARDSTONMA01337 ISSUED ON :3/22/2013 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL VT CASTINGS MONTPELIER WD
INSERT
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 3/22/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner