10-011 05/17/2013 13:17 FAX 14135388753 OLDE HADLEIGH HEARTH PAT 0002
The Commonwealth of Massachusetts runt rums
Department of Industrial Accidents
l_; V r—u-1 Office of Investigations
:"'2 1 1 Congress Street, Suite 100
: Boston,Ml 02114-2017
4."'.�:zo; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Olde Hadleigh Hearth&Home Center,Inc.
Address:119 Willimansett Street
City/State/Zip: South Hadley, MA 01075 Phone ,413/538-9845
Are you an employer?Check the appropriate box: Type of project(required):
1. a I am a employer with 8 4. [] I am a general contractor and I.
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2-❑ 1 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 Building addition
[No workers' comp. insurance comp.insurance.: $
required.) 5. 0 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.o Other Install wood stove
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box ttl 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,
tContractors 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:Travelers Insurance Home Improvement Contractor's Liscense#148198
Policy#or Self-ins. Lic.#:IEUB5197B81 ,,cp� Expiration Date: 7/12/2f013
Job Site Address: 5023 /f We* 6LE / City/State/Zip: A m D/�3
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.
1 do hereby certify under the 'aims andjenalties of_perjuly that the information provided above is true and correct
ature: � --- Date 8/10/2012
Phone#:538-9845 CS SL#9878'
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):
t.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
•
I �m '} il3
DEPARTMENT OF BUILDING INSPECTIONS Si
212 Main Street • Municipal Building
Northampton, MA 01060 :
DEPT.•
NORHAMP70N,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 # /67(e
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS 5-2� 3 Kf Ai� I-�
/y i.� K. G' 7°
1. Name of Applicant: J\I4) � I /
Address: 4 /knn E Telephone: 3 31(16/(K) ‘r77/C)
2. Owner of Property: /\111 I /,�}17/1 I 'r ( //1./
Address: 50 , Telephone:
3. Status of Applicant: X Owner Contractor
4. Type or Brand of Stove: Av 1 i d' Prey 0 LL rf Z
Contractor's Name: OLIV "A.f t TAT 0
Contractor's Address: I t \ W /A M S S I 5a:A 17\ f17L. r1-
Contractor's Phone: 13 6-3 - '1 1 `t 5 /
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: Cl / 7` APPLICANT'S SIGNATURE .! �rr� �� ,
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
523 KENNEDY RD BP-2013-1106
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10-011 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-2013-1106
Project# JS-2013-001827
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): 27704.16 Owner: ARAI NATHANIAL Y&KATHERINE A FIRST
Zoning:RR(100)/WSP(100)/ Applicant: ARAI NATHANIAL Y & KATHERINE A FIRST
AT: 523 KENNEDY RD
Applicant Address: Phone: Insurance:
523 KENNEDY RD (413) 586-3144 0 WC
LEEDSMA01053 ISSUED ON:5/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL AVALON PENDLETON 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 5/20/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner