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36-075 (9) 363 WESTHAMPTON RD BP-2016-1099 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 -075 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-1099 Project# JS-2016-001321 Est. Cost: $3000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD SCOTT 83108 Lot Size(sq. ft.): 93697.56 Owner: HOENER VIRGINIA zonini4: Applicant: RICHARD SCOTT AT. 363 WESTHAMPTON RD Applicant Address: Phone: Insurance: 20 BULLARD AVE (413) 478-6306 (� HOLYOKEMA01040 ISSUED ON:3/15/2014 0:00:00 TO PERFORM THE FOLLOWING WORK:HEARTHSTONE WOOD 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 3/15/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _ 5ity of Northampton �} 3 e r• � Massachusetts , U iR�). F, { F � D P NT OF BUXLDING INSPECTIONS '.. v — 12 in Street • 'Municipal Building DtP"i.OF r3tlii DINT It' .(Ti N NO, F h4fF1'GN,MtUcp Northampton, MA 01060 'sem... C� 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 : 1 Rv l w y a_ 4, (� Address: �� ( ���?�,T'1���u Pt,x�r�v Telephone: 2. Owner of Property : nV 1 VZ<. Address: 5 t) t Telephone: 3. Status of Applicant : Owner il­�Contractor 4. Type or Brand of Stove : e 11�_lis ­10 4,� Ljaob 5. Estimated Cost : T 3 d J Z) If applicant is not the homeowner:: Contractor name � r Construction Supervisor's License Number // Expiration Date " Home Improvement Contractor Registration Number. G C� �� Expiration Date '7L 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 is true and accurate to the best of my knowledge. DATE: 7 - APPLICANT'S SIGNATURE DATE: HOMEOWNER'S SIGNATURE APPROVED DATE: BUILDING OFFICIAL I I i The Commonwealth of Massachusetts Department ofIndustrial Accidents W Office of In vestigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information ` a Please Print Legibly Name (Business/Organization/Individual): `�- �(� l Address: �12-- 6), Pr r-C3) y� City/State/Zip: �..� r� (✓ Phone#3 E " 6 �e �6 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.[d,,�am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑ Building addition comp.[No workers' comp. insurance p• 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 11.0 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 13.❑ Other employees. [No workers' comp. insurance required.] Any applicant that checks box 41 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. #: lExpiration Date: _) Job Site Address: C'� !(� ' City/State/Zip: fl 6n 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 penal ies perjury that the information provided above is true and correct. Si ature: / 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#•