30A-052 ' /
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, _ .: Office of.Investigations
` / `1 I Suite 100
�.�� E£/ ��. Congress Street,
Boston, ��MA 02114-2017
wow/w.xmoma govydio
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please I'rint Legibly
Olde Hadleigh Hearth&Home Center Inc.��orne (8usim:s,X),gaoizmium|ndividvoU: ,— _ _________ `_
/\ddIe8S:119VYiUirnanoett Street
_______ __ ______ __--'__-__ ___-___ -____- _—''—__------'-
Ci ty/St4te/i i `• South Hadley, K8A01O75 _____ phV�� #�413/538-9845
— -- |
Arc you un employer? ��hookthe appropriate box: [ type of project(required):
|��� | am a employer with 8 __ 4� | 1 I am a general contractor and I 6 �� New construction
have (hosub-contractors � ' '
emp|uyccx (W| and�xpmr�dme!^
listed on the attached sheet. 7. Remodeling I mm a sole proprietor or partner-
These sub-contractors have no 8. II Demolition
�
employees have
wor�n� �rmcin any capacity_
� 9. [l Building addition
[Nowockcm' comp. insurance comp. ioourancr. ' '
required.] 5. rl We are ucorporation and its lo. Electrical repairs or additions
LII I ant a homeowner doing all work nf���mhu"c �xuris�6 /hu� | \ Fl Plumbing repairs or additions
myxe|[ [l�vvvorkrrx' co/np. h�h/«[c«»mp«im� pu' ��(]� I2��� Rou['�puiru
insurunceroquirud./ ' «. l52' Q|(4)` and wc have n^ �� �nuta|| woo
c/np\oyocx. [No workers' \3j/ 0\h�r________ " ^^"`~
_ ___ _ � comp� insurance _____ __
*Aity applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
` |*,uu"xncrs who submit this affidavit indicating they are doing all wink and then hire outside contractors must submit a new affidavit indicating such.
I CtOr5 thai cheek ibis box in ust attached an additional heei showing lie name of the sub-contractors in d state whic ihet v,not mv,uentities have
employees. I fthc stib-c&ijttraeiors have employees,they bus!provide their workers'eump.policy number,
. ==`
/oo/u000p69crtho/6/yn`vb6ngwnrkerx'coxpomxu/iooinxu/umcc}Ormyong//oyeus. Below/*the policy*oJ/ob site
information.
|nsoruooc[omyanyNumcT�vdeo ��u/ance Home |rnpn�van�enc[ontractur�ii»cense#�KB08 ___
� |EUB5107B81 7/12/2U14'
}`u|icydorSel�mo. Lie.#� Expiration Date: ___
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i ~ �� �)ohSiiuAJJrcm� v �/ / Y _ �hr/�u�/� p / �,� |� �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failurc to secure coverageas required under Section 25A oYMGI, c. 152 can lead to the imposition oferintinal penalties ofa
tine 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 tine
o[lip m $250.VOx day against the violator_ Be mvied that a copy of this statement may be forwarded to the Office ol
|nvos|i�odonx of the DIA for insurance covoru�u verification.
.
/ do hereby mrtify under the pains and penalties of perjury that the ittfirmation provided above A true and correct.
8/l0/201J
�iA/uu�re� r _ __ Date:
Phone 538-9845C8SL #98784
_____ ___ ______ ____ ____
_-_
Official use only. Bo not write bv this area,/o6e completed hy city or town official
City or Town: _ Pernik/License#_ _
ISSLI ing Authority (circle one):
1. Board of Health 2. Building Department 3. City/fowl) Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Per000: _ ___ __ �hnoo#�___� __
--
~
City of Northampton
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SEP I 6'''' 9.1).:!;:,-;:4,4,,,,. .
,,,:pARTMENT OF 5 Lti T.Dti...°5:5 I NSP ECT,T t:tr,t.tt
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Electric,Plumbing&Gas inspections
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: S25.00 Check # 1%
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If applicant is not the lwrneovimer,
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All Applicatt5 must comf)loto a Wm kers Compeusatima Insurance Affidavit b .frare we car is-sue a p'aanmt
, Certification: I hereby oortity that the information contained herein is true and accurate to the best
of my knowledge,
7
DATE: .1i^i, (1.7 I TS APPLICANT'S SIGNATURE . .1-:*--1
DATE: qii421.1416 HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
i I
i
61 LIBERTY ST BP-2014-0328
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-052 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-2014-0328
Project# JS-2014-000562
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.): 15594.48 Owner: WATSON DAMIAN A
Zoning: URB(100)/ Applicant: OLD HADLEIGH HEARTH & HOME CENTER
AT: 61 LIBERTY ST
Applicant Address: Phone: Insurance:
119 WILLIMANSETT ST (413) 538-9845 WC
SOUTH HADLEYMA01075 ISSUED ON:9/17/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL JOTOL 3CB 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 9/17/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner