23A-027 (2) ' Q The Commonwealth oj•Massachusetts
Department of Industrial Accidents
k Office of Investigations
600 Washington Street
Boston,MA 02111
vi
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: 2 e i)I-L-Pr a_ ) JA V
City/State/Zip:�d0L Phone.#: d r� � F� qb
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 6. ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet 7. E]Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑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.]t c. 152, §1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homdowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
2Contractors 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.M ,p Expiration Date:
q 1 r 1 �'� Ci /State/Zi (F •w�y�.
Job Site Address: ty P:
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 pains and penalties ofperjury that the information provided above is true and correct.
Signa ture: Dr C/ W� � ✓ Date:
Phone
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#:
A
ty of Northampton
OCT 3 0 2015 Massachusetts
W
AR OF BUILDING INSPECTIONS ?y.,
OF BUILDING INSPECTIC)R2 in Street • Municipal Building J6 QD
NORTHAMPTON MA 07060 Northampton, MA 01060
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD,COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OZFFI EP LACE INSERTS
Permit Fee•--47 Check# C9 q�
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: S' J /7 En I �s O A
Q Y a�Address: � I � I t.f� .,�Telephone: Y/11,may,
2. Owner of Properly: Q me,
Address: �Q c�r Telephone:
3. Status of Applicant: yOwner Contractor
4. Type or Brand of Stove: 1
If applicant is not the homeowner:
Construction Supervisor's License Number 3 :3 1 Expiration Date L�
Home Improvement Contractor Registration Number J �7 U 2 f Expiration Date i
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification:l hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: APPLICANT'S SIGNATURE
DATE: '/� S�^` a HOMEOWNER'S SIGNATURE `
APPROVED
DATE: BUILDING OFFICIAL
A
49 PARK ST BP-2016-0610
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:23A-027 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-2016-0610
Project# JS-2016-001020
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq.ft.): 9713.88 Owner: ERIKSON STEPHEN C&PATRICIA F
Zoning: URB(100)/ Applicant: ERIKSON STEPHEN C & PATRICIA F
AT. 49 PARK ST
Applicant Address: Phone: Insurance:
49 PARK ST (413) 586-1608D
FLORENCEMA01062 ISSUED ON.111212015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALLQUADROFIRE 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 OccuRancy Siznature:
FeeType: Date Paid: Amount:
Building 11/2/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner