19-007 (2) The COmmonwealth of lifac,:sochusetis
1 Department of.industrku.Accidents
Office filinvestioations
. ,
600 Ilasitin,von Street
• lioston„ifoss. 0211.1
1'4043,07'7' '
irww,11701s,gowilia
• Workers' Compensation insurance Affidavit: ilnilders/ContmetorsiEleetricians/Phinibers
. Ica nt Information Please Print Let-tail),
.,...,
Name 0311,-,i1wmr:organizatioriiiridiviclual):,..i. :• i 1 -4 • • -
i -z ,.'
Address: I , ,,,,,,,i i c-:.;:..14:-P-1:>-1' .',„(-7'• ,,S:.
.,..,
• . — m4,'''' N ....A /0
CitylStatetZip: &-ir ::731Y2.7.4.. ..(--T-7:-...-(7.-.(....A r;,-;el PhoneTh 4.-./ / :3 — 7 rr.'..,:':'
........._ ..... ,i____.... . ,
.....
I Are'on an employer?Cheek the appropriate box --— 1 TYPen--f-pr;:j.i:ei.(requit:e-di;"---------
. I.Vi I ain an cmployer with 1. L. I am a general contactor and I 6, L New construction
....,„. , ........,,_
1 :employees(full and/or pr c tinieY have hired the sitfiti..cOntrn.,2tciM
7. i..1.Remodclitue
2, ii 1 am a sole.proprietor or parnief- listed on•the aft-yelled sheet.
ship and have no employes ".1 beitre stib-contracters have t 8. 71 DernOlition
working for me in any capacity. e In irtoyees and have workers'
i 9. 71 Building addition
No svorkerst comp.ilistitance comp.insurance. ,i1
required] ,f,„.,J We,are a corporation and its j 10. 7l Electrical repairs e additions
•3. ri
I air a homeowner doing ail lyork officers have exercised their
1 t i. 71 Plumbing repairs or additions
I myself [No workers,' comp. right of exemption perm Mid.
I insurance required]? c, 152,,..`t 1(4),um/We have no 12, •,:il Roof repairs
emplevees, [no workers"
: 13.X, Other_
cone in'sliTan ,e,required:I
, .....
Arr:.applieetrit that checks box IA must also fill out the Section below s' sag their wnrkrrs'coniite'toolion poky information.
, fklomcossuers who submit this affidavit indicating they Ors doing all wort and then hire outside coulracitors must submit a sew affidavit indlealitsz sack.
:::Cortteictors thin check:this tan must attar+an additional sheet showing the nsme atilt sob conietictors and stole"udictliter in ma thasz cubes have employees. if
fhostili,7rOutratelors bays,,,c..22cesiAllev:nitistrfrvick,their,wdrkereconaltAity mint ber,
i am an employer that is providing.worker:'compensation inswance for my employees. nelow is the policy find job site
iprnwiltni.
i us u,:::itficse Corn p irny\am /-1 /1", rg t(:':::,i -44.4,,)41.4,,,, ,,x,,c.:.-
, ;
,..,/-,;,,, , J.,:i
PolicY.4 or Selnos.:tic'.It': L A I NC., '- ‘.1-)CiHn ''''''.-c 7.*:...":,'V::::3 F.x.cii.atiorl ft-to; ''>: ,. ,i f ._
. -.-. .,. ..... .. - -I-
.f 011 S i tc Address: CityiSnite."21p:
Attach a copy of the workers' ennmensat inn Volley deal ra awl page(showing the policy number And expiration (date)„
Failure to secure covernge as recillil'ed uudar Sc.ction 25a of:MGT, 152 can lend to the imposition of criminal penalties of a fine
Up lb$1,500.00 and/or one year imprisonment t.'" v,-el i es civil penalties in the lain of a STOP WORK ORDEK and a fine of
5250.00 a day against'violator. Re.advised thin a copy of this statement m:t IV ThrWarded to the Of fice of ItiNestiLotions of the
DIAfor coveratta-) voritication. _„„--.... .._, .. .-.. ..
t
tin her bY 4ler fil,i)under the pait,t,Lynd penalties of perjury Oat/he infiwinalion pi-os,inr.eti above is trtic and correct.
...
........._
.Si8-f_Ltia .!.. „..• .-, .,,,,, ."4„..-,..,..± ...---],l,„_ \ De,de• '"5,1:..'...'i f N
--' _.-----
.
Print Naine- 3i LN: r-7 : ... -: : ''
t ( C 7
til
,
1 Official use only Do net write in this area to be completed hi' city or town qfileial
City 4K TOWP: , , Permit/license#: ,._ _. ......
issuing Authority(circle one):
1 'Lltoard al-tea0i 2. Building Department 3,Cityifonit Clerk 4.Electrical inspector 5.Plumbing Inspector
n,
(ti hot-
i;
Contact poi-son: Phone it:
_ • ._ .._____........
„doommemow
�` (( I : 1 ��r='7r of Northampton
Jg I Massachusetts �.� .d r to
.;.,.; NOV - 4 2013 DEPAR I NT OF BUILDING INSPECTIONS ,`
I 21/ Ma n Street • Municipal Building .'
�� Northampton, MA 01060 c� 11 3-ysk"'T
rig,S G Inspections
Electric. Pig r " °"'
Ncrr'c,,n c! 1M4.A 010E0
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 # 0 7‘
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS 3<' i D A-11/4A C),-.1 t rt-I.q.MP r- 41
1. Name of Applicant: M I C IAA e"1.._ WC t Pr
Address: Sot P ' O J tP wean{A--"e.t'a pi Telephone: H 17 f8 `f '12_i
2. Owner of Property:, ._,,. ,ti. _,'.n .•. 'So R No)F CK‘E W l
Address: '0 C2O S e'y sr Or-rwv,Ci'U,1 .hone: 'i I 1 S s6 ci 9C7 i ci
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: I4h2M.k-A/ P'-I 3 'EuC S role
Contractor's Name: .7.,�6i4
Contractor's Address: /7c "4/.4--- _
Contractor's Phone: 0 /d k--2
Construction Supervisor's License Number: C 3S L-041 1 114 Expiration Date: `f/2-é l 2_o I if
Home Improvement Contractor Registration Number: f S 86 4I Expiration Date: 3/13 1 2_01y
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: it / 4 / 1 3 APPLICANT'S SIGNATURE -.-,
DATE: I I ' 4 //3 HOMEOWNER'S SIGNATURE ;,rL-- _ _ _' > I-)
1 i
APPROVED
DATE: BUILDING OFFICIAL
301 DAMON RD BP-2014-0568
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 19-007 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-2014-0568
Project# JS-2014-000946
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8319.96 Owner: LUCIA MICHAEL
Zoning: Applicant: LUCIA MICHAEL
AT: 301 DAMON RD
Applicant Address: Phone: Insurance:
301 DAMON RD (413) 584-4217 0
NORTHAMPTONMA01060 ISSUED ON:11/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL HARMAN P43 PELLET 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:
FeeTvpe: Date Paid: Amount:
Building 11/4/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner