18C-068 . The Commonwealth of Massachusetts
Department oflndustrialAccidents
`; - �=� �( — ' Office of Investigations
1 Congress Street Suite 100
..,,,„, Boston, MA 02114-2017
y'' �:y www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /Please Print Leiibly
Name (Business/Organization/Individual): ✓ C Z-1-7Z- c de, CZ '14 —
Address: 5-3 M fl� ► S-7--
City/State/Zip: a...17- 7CL-7 ilk Phone#: 3 3 t --7/7(
Are you -employer?Check the appropriate box: eVtas,''r Type of project(required):
1.[J J r a employer with 7 4. f I am ageneral contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.El I am a sole proprietor or partner- listed onthe 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 Q B tg addition
[No workers' comp.insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electricalrepairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. riglt of exerrption per MGL 12.❑Roofrepairs
insurance required.] ' c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*any applicant that checks box=1 must also fill out the section below shossin g their workers-compensation policy informati on
Homeowners who submit this affidavit indicating they are doing all work and thenhire outside contractors mist submit a new affidavit indicating such
Contractors that check this box mist attached an additional she et 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: / Ai —
Policy#or Self-ins. Lic.4: CC �'-®D 9 d',3 t` O t*v?F'-'/-� /9 Expiration D ate: 3 .( ^-2c l y
Job Site Address: 3 ('L /1_11- /1447179710)-City/State/Zip: ,4I
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Fa ure to secure coverage as required under Section 25A ofMGL 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 penalies in the form ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification
I do hereby certify 'e the j and penalties of perjury that the information provided above is trite and correct.
S',, .1 ure: ..AriA� Date: if '."--a 3 -13
ow
Phone 4:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Pen nit/License #
Issuing Authority(cirde one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: _ Phone#:
C'ty of Northampton
"' \, Massachusetts R
ra.
2 5 2013
It
' .. (�{ DEP NT OF BUILDING INSPECTIONS nT'
Ule� 212 Main Street • Municipal Building , ,:tv
Northampton, MA 01060 1"4 `'
Electnc P�umrinc<6,G pections
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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 #(XI VI 105----
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: `3 Gy /i ,97/6 `
Address: /a G / Z .c.c / Telephone: L`/_ ��e-2/
T11�� oih n/cJ?
2. Owner of Property: _. .GI T A) f/ti/
:.ress; '.� _ - .o& �1-/.. _" ' : Telephone: c27(/— 4'43V
i
3. Status of Applicant: Own-er Contractor / -� `
4. Type or Brand of Stove:_it 72'Cy /7/f 30/ /Lied 0 -—A. J`Zz y-
GO S lA16( 5 S Aar y i41 ,(
If applicant is not the homeowner:
Construction Supervisor's License Number Cs- 42i �G�3 _Expiration Date ^7�r� //-2?0 / or---
Home Improvement Contractor Registration Number_/63�' Expiration Date 7 `4 — yam/ —
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 i ' e and accurate to the best
of my knowledge. /3 DATE: /) A —/3 APPLICANT'S SIGNATURE_ _,./ t ` .. _
/0-21—.21913 1
DATE: HOMEOWNER'S SIGNATURE_ • . '.
APPROVED
DATE: BUILDING OFFICIAL
3 GLEASON RD BP-2014-0514
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C-068 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-2014-0514
Project# JS-2014-000883
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CZAR ENERGY SOLUTIONS 103963
Lot Size(sq. ft.): 6490.44 Owner: GIANESIN JUSTIN L&
Zoning:URB(100)/ Applicant: CZAR ENERGY SOLUTIONS
AT: 3 GLEASON RD
Applicant Address: P hone: Insurance:
53 N ELM ST (413) 536-7171 WC
WESTFIELDMA01085 ISSUED ON:10/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REGENCY H1301 WOOD INSERT
W/STAINLESS STEEL LINER
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 10/28/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner