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44-002 •. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street kv Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(BusineWOrganizationRndividual): C a- Address: �,n �3 L) City/State/Zip: 1b04 Phone.#: — 3 3 3`-10 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I ymployees(full and/or part-time).* have hired the sub-contractors 6. E3 New construction 2.al am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. # 9. E]Building addition 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 I LEI 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 employees.(No workers' I3.❑Other S 1 61/�- comp.insurance required.)Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homdowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ZContractors that check this box must attached an additional sheet showing the name of the sub-co-tractors and state whether or net those entities have employees. If the subcontractors 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 Self-ins.Lic.�M [' Expiration Date: ( Job Site Address: F06 i LDkewe, i City/State/Zip: �,t� f�cPi,C � 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. I do hereby certify under�the pains and penalties of perjury that the information provided above is true and correct. Signature: 6 1 W�j�7c_.Vr Date: — Phone M "1 I I S 7.7 J2 YD 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) R'31 p / ?1�.. 14 t RU -T-1— icense Number Expiration Date Name of CSL-Holder List CSL Type(see below) V Description Address 1� 0 L-"f B K Type Unrestricted u to 35,000 Cu.Ft. Signature •+ R Restricted I&2 Family Dwelling M Mason Onl y-1•2 5-3 5 -A 3 4 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Reg'stered Home Improvement Contractor(HIC) R lc,w A z0 .,t'C,0 T l 6 0 9 HIC Company N e or HIC Registrant Name Registration Number z,G u age, R-b��{�ke� Address d 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........... O 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 9 SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION V 1> ,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. Tint � Name —2- v Signature of Owner or Authorized 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 program 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3_ "Total Project Square Footage"maybe substituted for"Total Project Cost" r, The Commonwealth of Massachusetts FEB 2 6 20M Bdar of Building Regulations and Standards FOR Massac use State Building Code,780 CMR,Th edition MUNICIPALITY USE Eiecf r actions Revised January I,2008 PERMIT APPLICATION FOR SOLID FUEL BURNING APPLIANCE Signature: Building Commissioner/Inspector of Buildings Date SECTION l:SITE INFORMATION 1.1 Pro rty Ad ess: 1.2 Assessors Map&Parcel Numbers �r � t �/1i 1.1 a Is this an accepted street?yes i Z no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 15 Building Setbacks(R) 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 D Private D Zone: _ Outside Flood Zone? Municipal D On site disposal system D Check if SECTION 2: PROPERTY OWNERSHIP 2.1 Ow r of Reco Name t) Address for Service: 0'3U 3, Si Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check a_ll that apply) New Construction D Existing Building D Owner-Occupied D Rgx&s(s) D Alterations) D Addition D Demolition D Accessory Bldg.D Number of Units Other D Specify: -sj 0 y e- Brief Descnption of Proposed C rl: L'_ 6 ` l2. SECTION 4:ESTIMATED-CONSTRUCTION COSTS Item Estimated Costs: Official Use.O�j► and Materials 1.Building $ 1. Building Permit Fee:S Indicate.how fee is determined: 2.Electrical S D Standard City/Town Application Fee D Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) S Lists _ S.Mechanical (Fire Suppression) S Total All Check N i Check Am Cash Amount: 6.Total Project Cost: S � � � D Paid in Full D Outstanding Balance Due: 900 FLORENCE RD BP-2014-0913 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:44-002 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: woodstove BUILDING PERMIT Permit# BP-2014-0913 Project# JS-2014-001579 Est.Cost: $3400.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD SCOTT 83108 Lot Size(sq. ft.): 13852.08 Owner: PARENT JOSEPH M&SANDRA L Zoning: Applicant: PARENT JOSEPH M & SANDRA L AT. 900 FLORENCE RD Applicant Address: Phone: Insurance: 900 FLORENCE RD (413) 519-0338 O FLORENCEMA01062 ISSUED ON:212612014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 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 2/26/2014 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner