35-191 (8) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Richard Scott
Address: 20 Bullard Avenue
City/State/Zip: Holyoke, MA 01040 Phone #: (413) 533-6340
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
employees(full and/or part-time)." have hired the sub-contractors 6. ❑ New construction
2.. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working or me in an capacity. employees and have workers'
g y p y' 9. E] Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.E] Other
�' (.� �
comp.insurance required.] )
`Any applicant that checks box#I 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. Ifthe 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 anti job site
information.
Insurance Company Name: —
Policy#or Self-ins. Lic.#: / Expiration Date:
Job Site Address: �� ( I L) �,� 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 certify under the,pai s d nplt, perjury that the information provided above is true and correct.
Signature: _ + Date:
Phone#: r�
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#:
kf_ . C ty of Northampton
S.�
Massachusettsw� �
Y
L ,t 1�tiy. DE P TMENT OF BUILDING INSPECTIONS a "
EP 1 C aTpN.R,A 01060
No-,,TNAsi 212 Main Street • Municipal Building y �.
Northampton, MA 01060 syjt �i�
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 # 27--
_
PLEASE PE OR PRINT ALL INFORMATION
1. Name of Applicant: k ( ,`( ��� I
Ll Address: !:_(� �l ,C� Telephone:_�_1 _ ��� (—•�
J,/2. Owner of Property: /� /i6-eJ r/
�J Address: /,Z t!J Lfi JT /� Telephone: y��
3. Status of Applicant: Owner contractor
i
4. Type or Brand of Stove:
If applicant is not the homeowner:
Construction Supervisor's License Number eJ 1 �✓� Expiration Date
Home Improvement Contractor Registration Number U Expiration Date ` T
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.
1, !1
DATE: 4 ^ �-� f u APPLICANT'S SIGNATURE ��AA
DATE: 1 HOMEOWNER'S SIGNATURE � '--
APPROVED
DATE: BUILDING OFFICIAL
1214 BURTS PIT RD BP-2016-0664
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 191 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-2016-0664
Project# JS-2016-001111
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sa. ft.): 12196.80 Owner: LYNCH ELIZABETH
zoning: Applicant: LYNCH ELIZABETH
AT. 1214 BURTS PIT RD
Applicant Address: Phone: Insurance:
1214 BURTS PIT RD (413 -0078 (�
FLORENCE ,MA01062 ISSUED ON.1111212015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL QUADRAFIRE E-2 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 11/12/2015 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner