29-308 (7) The Commonwealth of Massachusetts
-- --- Department of Industrial Accidents
,l Ft Office of Investigations
t ; 1 Congress Street, Suite 100
,
Boston,MA 02114-2017
k_ www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (t;usincss/Organization/Individtizil): BERNARDSTON FARMERS SUPPLY
Address:43 RIVER STREET
City/State/Zip: BERNARDSTON MA 01337 Phone #:413-648-9311
Are you an employer? Check the appropriate box: Type of project(required):
1.R I am a employer with 10 _ 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub-contractors 6. ❑ New construction
2.❑ I 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' ❑ Building addition
[No workers' comp. insurance comp. insurance.'.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ l am a homeowner doin��all work I
myself. No workers' com�. right of exemption per MGL
} [ 1 12.0 Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp. insurance required.]
"
Any applicant that checks boy#1 must also fill out the section bclott showing their workers*compensation policy information.
I lomcomiers Who submit this af7itlat°it indieatingthey are doing all work and then hire outside contractors must submit a nett affidavit indicatilla such.
...Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities hat r
cmplotees. ll the sub-contactors have employees,then must provide their workers'comp.polic)'number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the polio'and joh site
hi f ormation.
Insurance Company Name: PEERLESS INSURANCE
Policv # or Self-ins. Lic. #:WC8165644 Expiration Date: 7/1/15
Job Site Address: '3+ k!reh!'oole `Z)r City/State/Zip:
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
tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5250.00 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.
1 tlo hereby certy'1-•u'nder the pains and en/alltties of'perjury that the information provided above is true and correct.
Siunature: Cam / d� Date:
Phone 9:
Offrc•ial ttse only. Do not write in this area,to be completed by city or town official.
Citv 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#:
1J11 W` I - o rthamp
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SINGLE oR TWO PAMILV SnLin FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES. OR FIREPLACE INSERTS
Permit Fee: $25.00 Check
PLEASEt TYPE OR PRINT ALL INFORMATION
1. Name of Applicant
Address: I7rcI l i 15f r =;,h /�`I 1•� Telephone:
2_ Owner of Properly: /n��
Address:_3 �� &L r e b r o c fie 71 r Telephone; V/,�r U 3
3_ Status ofApplicani Owner Contractor
d. Type or Brand of Stove: I4)',9 Z2 "1 A t-j
If applicant is not the homeowner
Construction Supervisor's License Number �/' � �� Expiration Date
Home Improvement Contractor Registration Number Expiration Date
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; 104 /"/ ` APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE- BUILDING OFFICIAL
382 ACREBROOK DR BP-2015-0419
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-307 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-2015-0419
Project# JS-2015-000748
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 44300.52 Owner: NATALE JAMES F JR&CLAUDIA J
Zoning: Applicant: BERNARDSTON FARMERS SUPPLY
AT. 382 ACREBROOK DR
Applicant Address: Phone: Insurance:
43 RIVER ST (413)648-9311 O WC
BERNARDSTONMA01337 ISSUED ON:1011012014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL MARMAN PGIA 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 10/10/2014 0:00:00 $25.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner