38B-310 °-� The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
applicant Information Please Print Legibly
Name (Business/Orsani-r_ation/Individual):AFS d/b/a/ THE FIREPLACE
Address:106 STATE ROAD
City/State/Zip:WHATELY, MA 01093 Phone#:413-397-3463
Are you an employer?Check the appropriate box:
Type of project(required):
1.Q✓ I am a employer with 10 employees(full and/or part-time).* 7. E]New construction
2.�1 am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling
any capacity.[No workers'comp.insurance required.] !
9. ❑Demolition i
3_[3 1 am a homeowner doing all work myself[No workers'comp.insurance required.]'
-
-t.I I am a homeowner and\rill be hiring contractors to conduct all work on my property_ l will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 1 L[:]Electrical repairs or additio:-
proprietors with no employees.
12.❑Plumbing repairs or additic}::s
5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.-
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152 §1(4).and we have no employees.[No workers'comp.insurance required.]
*Am applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeo�.sners who submit this affidavit indicating they are doing all work and then hire outside contractdrs must submit a new affidavit indicating sue!-:
`Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities ha\e
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ani an employer that is providing workers'compensation insurance for my employees. Below is the polich and job site
information.
Insurance Company Name:MA RETAIL MERCHANTS WC GROUP, INC
Policv Y or Self-ins. Lic.#:014,0005033601115 Expiration Date:1/1/2016
,lob Site Address: 5-o e" City/State/Zip: d t ryp Q d1060)
.attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500 0!i
and/or one-vear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$?50-0cl a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance
coverage verification.
I do hereb},certifKICIL seder the pains and � talties of perjury that the information provided above is trite and correct.
Sivnature: �-f'�* Date: /D c��-�s
Phone 9:413-397-3463
Official use only. Do not write in this area.to be completed by city or town official.
Cite 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
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
.-.� Northampton, MA 01060 !{'tq
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET,CORN,STRAW OR SIMILAR STOVES, OR FIREPLACES
Check#
Please fill in all appropriate information ]
1. Name of Applicant :
Address: f a6 V54 k '?I_ W� k 14 01073 Telephone:
2. Owner of Property : ,j '7F ✓1 �P/11
Address: 5-0 1 d> S� f Telephone:
3. Status of Applicant : Owner y Contractor
4. Type or Brand of Stove : Orsa .5//0
5. Estimated Cost
If applicant is not the homeowner::
Contractor name /JOU 4S I Abb
Construction Supervisor's License Number 9`7k/0/ Expiration Date
Home Improvement Contractor Registration Number / ?OV Expiration Date
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
6. Certification: I hearby certify that the information contained herein rue and accurate to the best of my
knowledge.
DATE: l APPLICANT'S SIGNATURE
DATE: / ?d HOMEOWNER'S SIGNATURE —" —
r
APPROVED
DATE: BUILDING OFFICIAL
50 FORT ST BP-2016-0557
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-310 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-2016-0557
Project# JS-2016-000922
Est. Cost: $800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 20037.60 Owner: FENTON STEPHEN
Zoning: URB(100)/ Applicant. BERNARDSTON FARMERS SUPPLY
AT: 50 FORT ST
Applicant Address: Phone: Insurance:
43 RIVER ST (413) 648-9311 O WC
BERNARDSTONMA01337 ISSUED ON.1012212015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL MORSO 2110 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 Sienature:
FeeType: Date Paid: Amount:
Building 10/22/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner