24A-239 (5) 54 PILGRIM DR BP-2016-1342
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A -239 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 IUILDING PERMIT
Permit# BP-2016-1342
Project# JS-2016-002308
Est. Cost: $3750.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 10280.16 Owner: RYAN BAIWARA J TRUSTEE
toning. URA(100)/ Applicant: RYAN BARBARA J TRUSTEE
AT. 54 PILGRIM DR
Applicant Address: Phone: Insurance:
54 PILGRIM DR (413) 923-2999 O
NORTHAMPTON MAO 1060 ISSUED ON.5/17/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL QUADRAFIRE 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 CITE'OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/17/2016 0:00:00 $40.00
212 Main Street,Phone(413)5.87-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •IIMunicipal Building b
Northamptoh, MA 01060
SINGLE OR TWO FAMILY SOLID''FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD,COAL,PELLET,CORN,STRAW OR SIMILAR STOVES,OR FIREPLACES
Check# X53 4zlo
Please fill in all appropriate information
1. Name of Applicant :_ A R P( {�
Address: LI P1 LG R \ M R Telephone: L Z
2. Owner of Property :_ D A IL Py Rv 4 A p
Address: 5 y ��� a m Telephone: 9 19 11
3. Status of Applicant : Owner Contractor
4. Type or Brand of Stove : )ac61 T
a�
5. Estimated Cost : 3 SD
If applicant is not the homeowner::
Contractor name R[c.4-4
Construction Supervisor's License Number 0 IF 31 (Y—F Expiration Date
Home Improvement Contractor Registration Number 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 is true and accurate to the best of my
knowledge.
DATE: p ll APPLICANT'S SIGNATURE
DATE: S ' .V HOMEOWNER'S''SIGNATURE
APPROVED &�,Zv
DATE: BUILDING OFFICIAL
The Commonwea4h of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washtn gton Street
Boston,AVIA 02111
www.mays.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. ] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. F-] We are a corporation and its 10.1-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. o workers' com right of exemption per MGL
Y � P• 12.❑ Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees, [No workers' 13.F-1 Other
comp. insurance required.]
"Any applicant that checks box#1 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.
tContractors 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.L#: ) Expiration Date:
Job Site Address: J `I �� i �- ' City/State/Zip: P6
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 M L 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 d p�en(�lties of perjury that the information provided above is^true and correct.
Signature:
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/Towtl Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
I
Contact Person: Phone#: