03-026 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): R)C, (
Address:
City/State/Zip: L-4 8--SL n� U-1 U Phone#: C S �7
Are you an employer? Check the appropriate box: Type of project(required):
1. L I am an employer with 4. L I am a general contractor and 1 6. L New construction
employees(full and/or part time).* have hired the sub-contractors 7. d Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ;1 Demolition
working for me in any capacity. employees and have workers' 9. 7 Building addition
[No workers' comp. insurance comp. insurance. I
required] 5.1j We are a corporation and its 10. 1 Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their H. � plumbing repairs or additions
myself [No workers' comp. right of exemption perm MGL
insurance required] t c. 152, § 1(4),and we have no 12. 7 Roof repairs
employees. [no workers' 13, Other -?'Tj It t0
comp. insurance required.]
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
f"omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains q nd penalties of perjury that the information provided above is true and correct.
Sign ture: Date: �--
,� �� l
Print Name: �� 1 C�14 Phone#• 11 �
S
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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
�t , r ---- . of Northampton
S S
f Massachusetts w� 1
Ll
DEC 15 201gEPAIt OF BUILDING INSPECTIONS
212 Mai Street • Municipal Building
-- _-_�� orthampton, MA 01060
l 6ClIOIIS
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 # d of G
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: c �
Address: U t.�- _ �i/�C VFW Telephone:
2. Owner of Property:
L-," Address: C F? Telephone:
t,, 3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove:_ fz YT\ F'i >�� C- ° t\
If applicant is not the homeowner:
Construction Supervisor's License Number C> Expiration Date
Home Improvement Contractor Registration Number.__ Expiration Date u
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: 1 hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: -2z— 1 _ J APPLICANT'S SIGNATURE
DATE: ) f _JYHOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
583 COLES MEADOW RD BP-2015-0663
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 03 -026 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-2015-0663
Project# JS-2015-001274
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. 1): 80019.72 Owner: FLYNN JAMES
Zoning: RR(100)/WSP(100)/ Applicant: FLYNN JAMES
AT. 583 COLES MEADOW RD
Applicant Address: Phone: Insurance:
583 COLES MEADOW RD (413) 244-8624 (�
NORTHAMPTONMA01060 ISSUED ON.12/15/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL HARMAN ACCENTRA 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:
FeeTvve: Date Paid: Amount:
Building 12/15/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner