24D-040 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
i° 1 Congress Street Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): AFS Cdb/a THE FIRE PLACE
Address:106 STATE ROAD
Cit !Statelip:WHATELY, MA 01093 Phone 4:413-397-3463
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with 10 4• ❑ I arm a general contractor and I
employees(full and/or part-time).
* have hired the sub-contractors 6 E]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'
{[No workers' comp. insurance comp. insurance.= 9. E] Building addition
required.] 5. ❑ We are a corporation and its I 0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs
insurance required.) ' e. 152,§l(4),and we have no
employees. [No workers' 13.[]Other
comp, insurance required.]
*Arty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 iltc sub-contractors have employees,they must provide their workers'comp.policy number.
I ant apt enlplover that is providing workers'compensation insurance for my en:plUees. Below is the policy and job site
information.
Insurance Company Name:MA RETAIL MERCHANTS WC GROUP INC
Policy# or Self-ins. Lie. #:014005033601114 Expiration Date:
1-1-16
Job Site Address: �`� �/ ,; �c S't City/State/Zip: A/c r-- , n.P/c,r\
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 S 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 S250.00 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 certif1under the pains and penalties ofperjury that the information provided above is true and correct
Sit*_nature: 0Ckz.,
Date
�— l�
Phone : 413-397-3463
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.CityfTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Z-d 69K-L6£-E I.b aoeld end eyl
. C Q of Northampton
- Massachusetts �^?
MAY �8
2915 °
lNT OF BUILDING INSPECTIONS ,
n,
'n Street • Municipal Building
�`: pt;%cv, rj" "."..•• i� Northampton, MA 01060 B�,jY... 1�•1
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#
PLEASE TYPE OR PRINT-ALL
LI INFORMATION
1. Name of Applicant: �i'C ! �'r� ��ex e� i)c ug/ccs
Address: /O S7Q'7�� �' �/ri��c lyj,'nP --1i a9,-1elephone:
2. Owner of Property: ec V,4,-( /
Address: / 93 �/�eS�cr7� /✓prl)laryf yV' Telephone: `/� 6'5-4 �
3. Status of Applicant: Owner Contractor
4, Type or Brand of Stove:
If applicant is not the homeowner:
Construction Supervisor's License Number `V6/ Expiration Date
Home Improvement Contractor Registration Number > i�j y 7 7 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
DATE: ��� HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
L'd eoeid e.I°d e41
193 PROSPECT ST BP-2015-1189
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-040 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-2015-1189
Project# JS-2015-002228
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 6882.48 Owner: TAGHAVI RAVYA
zoning URB(100)/ Applicant: TAGHAVI RAVYA
AT. 193 PROSPECT ST
Applicant Address: Phone: Insurance:
P O BOX 7 WC
NORTHAMPTONMA01061-0007 ISSUED ON:512812015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL HARMON ACCENTRA 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 SiEnature:
FeeType• Date Paid: Amount:
Building 5/28/2015 0:00:00 $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
193 PROSPECT ST BP-2015-1189
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catefzorv: woodstove BUILDING PERMIT
Permit# BP-2015-1189
Pro iect# JS-2015-002228
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sa. ft.): 6882.48 Owner: TAGHAVI RAVYA
Zoning URB(100)/ Applicant. TAGHAVI RAVYA
AT. 193 PROSPECT ST
Applicant Address: Phone: Insurance:
POBOX7 WC
NORTHAMPTONMA01061-0007 ISSUED ON:512812015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL HARMON ACCENTRA 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: L 1
Final: Smoke: Final: ��a/ 6 4C7
THIS PERMIT MAY BE REVO Y THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE TIO S.
Certificate of Occupancy Signature:
FeeType' Date Paid: Amount:
Building 5/28/2015 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner