23D-045 The Commonwealth of Massachusetts
Department of Industrial Accidents
a Office of Investigations
I Congress Street, Suite 100
vie Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I r Please Print Legibly
Name (Business/Organization/Individual): 14 1 CL 4 (A ` -,/ t° �1 �1 1 V A-
Address: 1 k Ct �( Vryc t � c -byl UIC
City/State/Zip-, II&C&(C n�A 01�?& a Phone #: q j 3 V S V q1 I
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
* have hired the sub-contractors 6• E]New construction
employees (full and/or part-time). 7, Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ g
ship and have no employees These sub-contractors have g, E] Demolition
working for me in any capacity. employees and have workers'comp. E] Building addition
[No workers' comp. insurance comp. insurance.
equired.]
5. E] We are a corporation and its 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
right of exemption per MGL
myself. [No workers comp. 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.V0ther U,,(kf S-f�1_
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 certi y nder the_pains and penaltie of perjury that the information provided above is true and correct.
Si nature. jDat e:Phone � 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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i4 P P (r `�" i y of Northampton
Massachusetts
Q max.
DEC 2 2014
�✓ � ail
` r TMNT OF BUILDING INSPECTIONS j
212 Main Street • Municipal Building
-,Pac+.ions Northampton, MA 01060W"` ��
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# 3 a 0 1P
rr__ PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: �� (� V' ( P V-\ J i I Q� ✓c
Address: 110� �� ��s l C1 F1 2tl Telephone:"I I 1� J
2. Owner of Property: V-A e,
Address: Telephone:
/ (' 7r\
3. Status of Applicant: /Owner Contractor P tC lJ
4. Type or Brand of Stove: ���� l✓� ( �- V�-
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: APPLICANT'S SIGNATURE L,
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
119 RIVERSIDE DR BP-2015-0693
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-045 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-2015-0693
Project# JS-2015-001343
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 12806.64 Owner: SILVA KATHLEEN E&NANCY GONZALEZ
Zoning. URB(100)/ Applicant: SILVA KATHLEEN E & NANCY GONZALEZ
AT: 119 RIVERSIDE DR
Applicant Address: Phone: Insurance:
119 RIVERSIDE DR
FLORENCEMA01062 ISSUED ON.1213012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL BRECKWELL PELLET 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 Signature:
FeeType• Date Paid: Amount:
Building 12/30/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner