32C-130 (21) To Steve Brown Page 2 of 3 2014-11-20 17.33 12 (GMT) 1 41 351 70622 From: Kevin Thompson
11/18/2014 14:36 FAX 4135850417 PAI2AWSF_COPIES (j001/002
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
IV Boston,MA 02114-2017
www.mass.govidia
Workers' Compei sation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatio 1 PIease Print Leisibly
Dame(Business/Organizatic Vnndividual): aso kvy'
Address:
city/state/zip; Phone#.
Are you an employer?Che-k the appropriate box: Type of project(required):
1.❑ Tam a employer with_ 4. [j I am a general coat vzwr and I
employees(full and/arj art-time),
r have hired the sub-contractors 6. ❑New construction
2 1 am a sole proprietor o: partner listed on the attached sheet. 7. 0 Remodeling
ship have no em to/ees These sub-contractors have
P P $. ❑Demolition
working for me in any•apacity. employees and have workers' 9 Buis addition
[No workers' comp.ins'trance comp.insurance,$ ❑
r1uired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am ahomeowner doin; all work offictirs have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'cc mp, right of exemption per MOL 12.0 Roof repairs
insurance required-]t c.152, §1(4),and we have no
employees.[No workers' 13.0 Oth*,Oclk, - .
comp.insurance required.] (Y- -T',
*An y applicant that checks box#1 mug also fin out the section below showing their workers'enmpensation policy information.
I Homeowners who submit this affidav) indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
tcannacwrs that check this box must at ached wi acMitional sheu showing the nave ofthe sub-mvoaecots and state whotber or not those entities have
employees. If the sub-contractors have mployees,they must provide their work=,comp.policy number_
lam an employer that isprovid''ng workers'compensation insurance for my employees. Below is Mepolicy 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 req sired 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-}ear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a ale
of up to$250.00 a day against th, violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA for iusi rance coverage verification.
I do hereby cerl#y under the al is and penalttes ofperjur�thatforrnatloa provided above is true and correct �-
Si tore: --- Date.
Phone
Official use only. Do not writ,in ihls area,to be completed by city or town gfflcial
City or Town: Perm it/License#
Issuing Authority(circle one)
L,board of Health 2.Buildin;Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
To. Steve Brown Page 3 of 3 2014-11-20 17 3312 (GMT) 1 41 351 70622 From: Kevin Thompson
a
11/18/2 14 14:37 FAX 4135850417 PARADISE.-COPIES 2002/002
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City of Northampton
['Uj f!� l N n Massachusetts �~'� x�"�z% rXVARna2gT OF BUXIr XM TNSVZ4C=ONS
�F 21.2 Main Str*et • MInioipsl Building
�� LL 90vthaepton, H& 01060
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0
SINGLE OR IWO FAMILY SOLID FUEL. APPLIANCE PERMIT APPLICATION
FOR WOOD,COA-PELLET,CORN,STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $26:00 Check# 4f q
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 'i` a 4 ry
Address: ya (4r�
2. Owner of Property_ ��w t�i 11 L✓f/1
. Sy AZ p
Address:
/"A n 1�h ,f7 <N1 Tele hone: 41 /61 �
3. Status of Applicant_____Owner ,Contractor �)
4. Type or Brand of Stc ve-
If applicant is not the iomeowner
Construction Supervisor's License Number. j�5 q? EXPiration Date �!O
Home Improvement Conb actor Registration Number F)rptraton Date
All Applicants must -ompleto a Workers Compensation Insurance Afdavitbefare we can Issue a permit
5. Certification:I tereby certify that the Information contained'herein is true and accurate to the best
of my knowteda 3. fr,
DATE: l APPLICAmrs SIGNA a URE
DATE:I� L -V' 40 OWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
74 CONZ ST BP-2015-0606
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 130 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2015-0606
Project# JS-2015-001170
Est. Cost:
Fee: 525.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEVIN THOMPSON DBA K & F MASONRY 105698
Lot Size(sq. ft.): 22128.48 Owner: BROWN STEPHEN A
Zoning: URC(100)/ Applicant. KEVIN THOMPSON DBA K & F MASONRY
AT. 74 CONZ ST
Applicant Address: Phone: Insurance:
76 HARVARD ST Liability
SPRINGFIELDMA01109 ISSUED ON.121112014 0:00:00
TO PERFORM THE FOLLOWING WORK.WOODBURNING STOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si$jnature:
FeeType: Date Paid: Amount:
Building 12/1/2014 0:00:00 $25.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner