12C-076 ' The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): L
Address: Zd 1 y L L AA
City/State/Zip: C.`' Phone.#: D
Are you an employer? Check the appropriate box: Type of project(required):
1.El am a employer with 4. [] I am a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.1ZI 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'
insurance.$ 9• ❑Building addition
[No workers' comp.insurance comp.
required.] - 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees.[No workers' 13.❑Other S 1 e-
comp.insurance required.] NS'T 14 L Z--
'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.
1Contractors 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:
Policy#or Seif-ins. Lic.##: Expiration Date:
Job Site Address: r(�S— /►'(a �j Z-1/I City/State/Zip: / l
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
Investi,gations of the DIA for insurance coverage verification
I do hereby certify under�fit e pains and penalties of perjury that the information provided above is true and correct.
)
Signature: 6/5!� 1e�t�'� D Date: /V -2.Z-" lLI
Phone M `7 13 .S �� O� y D —
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#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) _R31 0 9 6 _ 9
/ 1
r}h I,--0 TC, License Number Expiration Date
Name of CSL-Holder ,V
2.� •�y�L �R a �Y 2 List CSL Type(see below) V
Address 1 0 L\ B K Type -Description
U Unrestricted(u to 35,000 Cu.Ft.
Signature —�� R Restricted 1&2 Family Dwelling
!: M Mason Only
(3 J 4
Telephone RC Residential Roofing Covering
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Im rovement Contractor(HIC)
RlCWAzs '�� _ 160 29
HIC Company N e or HIC Registrant Name Registration Number
Address
1 / _ Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Er No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I-Lt Y ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Huv*
Print Name y ,�
Signature of Own "or Auth6rized Agent Date
(Signed under the pains and penalties of perjury
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
grogram or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR,7'h edition MUNICIPALITY
USE
Revised January
I,2008
PERMIT APPLICATION FOR SOLID FUEL BURNING APPLIANCE
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Addr 1.2 Assessors Map&Parcel Numbers
�Ry
I A a Is this an accepted street?yes \ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
r Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private D Zone: _ Outside Flood Zone?
Check if yesD Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' '
2.1 Owner of Record: 14
Name(Print) Address for+Service:
i Ql,l n(�l� laV 3
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction D Existing Building D Owner-0ccupied D Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition D Accessory Bldg.❑ Number of Units Other A Specify: -ST is y e-
Brief Description of Proposed Work': L(_ 6 L p,,
1=1 fro
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only.
I.Building S 1. Building Permit Fee:S Indicate bow fee is determined:
2.Electrical D Standard City/Town Application Fee
D Total Project Cost?(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) S List
5.Mechanical (Fire
Suppression) Total All Fees
Check No.L,�_C Check Amoun. (�'`J Cash Amount:
6.Total Project Cost S O Paid in Full 0 Outstanding Balance Due:
15 MARY JANE LN BP-2014-0831
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-076 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-2014-0831
Project# JS-2014-001438
Est. Cost: $2800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 10018.80 Owner: HUNT CHRISTOPHER
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: HUNT CHRISTOPHER
AT. 15 MARY JANE LN
Applicant Address: Phone: Insurance:
15 MARY JANE LN (802) 236-6073 ()
FLORENCEMA01062 ISSUED ON:112812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SANTE FE 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:
FeeType• Date Paid: Amount:
Building 1/28/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner