16A-006 (6) i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
xr� Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Richard Scott
Address: 20 Bullard Avenue
City/State/Zip: Holyoke, MA 01040 Phone #: (413) 533-6340
Are you an employer? Check the appropriate box: Type of project (required):
I.❑ I am a employer with 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 g• ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
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 11.0 Plumbing repairs or additions
myself o workers' com right of exemption per MGL
Y � P• 12.F-1 Roof repairs
insurance required.) t 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 showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating 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 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 Self-ins. Lic. #: Expiration Date:
Job Site Address: 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
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 aims and Penalties of perjury that the information provided above is true and correct.
Signature: Date.
Phone#:
Of 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#:
City of Northampton
4'^ Y Massachusetts
TMENT OF BUILDING INSPECTIONS
Main Street • Municipal Building
—�' (� � y 201/{ Northampton, MA 01060
t
OCT 0 4
k
Electric,Piumbinq&Gas Inspections
SI SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check # 8
L PLEASE TYPE R PRINT ALL INFORMATION
^ 'aJ'
PROPERTY ADDRESS (
1. Name of Applicant:_"4J u�'►'t�J�, CZ' ,/ I
Address: /J C- v3 fe r f !� � )21,1 LQ� Telephone: r' � 13
2. Owner of Property: Ju►YL'�J a✓)
Address: -15- CIQ41e,4 1 1 LIU Telephone:
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove -,�a U e 1 l 0
Contractor's Name: Richard Scott
Contractor's Address: 20 Bullard Avemue, Holyoke MA 01040
Contractor's Phone: (413) 533-6340
Construction Supervisor's License Number: 83108 Expiration Date: 06/14/2016
Home Improvement Contractor Registration Number: 160629 Expiration Date: 08/08/2016
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: G� ! APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
75 CHESTERFIELD RD BP-2015-0511
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-006 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2015-0511
Project# JS-2015-000961
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft. : 280.28 Owner: RYAN JAMES M&CHRISTINE H TRUSTEES
Zoning. URA(100)/ Applicant. RYAN JAMES M & CHRISTINE H TRUSTEES
AT.- 75 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
75 CHESTERFIELD RD (413) 584-1319 (�
LEEDSMA01053 ISSUED ON.10/31/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL RAVELLI 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 Sillnature•
FeeType: Date Paid: Amount:
Building 10/31/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner