08-065 (3) 336 COLES MEADOW RD BP-2021-0967
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:08-065 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Wood Stove BUILDING PERMIT
Permit# BP-2021-0967
Project# JS-2021-001662
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HARLOW BUILDERS 111205
Lot Size(sq. ft.): 78843.60 Owner: HARLOW SCOTT C&PAMELA J
Zoning: RR(100)/WSP(100)/ Applicant: HARLOW BUILDERS
AT: 336 COLES MEADOW RD
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586-0465
NORTHAMPTONMA01060 ISSUED ON:3/8/2021 0:00:00
TO PERFORM THE FOLLOWING WORK: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: d.K 3-j1-ZI I� Q
Rough: Oil: Insulation:
Final: Smoke: Final: Q,r 3_ Il-Z l IZQ
THIS PERMIT MAY BE REVOKED BY THE CITY OF N it i'TH,i PTO UPn IOLATION OF
ANY OF ITS RULES AND 7,TIONS. V
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Certificate of Occupancy ! Signature:
FeeType: Date Paid: Amount:
Building 3/8/20210:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
z r.�oa �4 yes. « arc
- [/' Massachusetts `9} !4G
DEPARTMENT OF BUILDING INSPECTIONS ;�er
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w a 212 Main Street • Municipal Building c''.,
Na ? Northampton, MA 01060 �
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N LICATION FOR SOLID FUEL APPLIANCE INSTALLATION
Property Information
Owners Name: Sc WeLAck).)
Address: 3 G Qc rt\eck. ( am
(No.) (Street Address)
Phone: Cell: 1113—3)5—v, il: ck \ b v.; ‘,5 �1Q��• c,v;'f\
Owners Signature: y_,?��¢t Date: `3t a /
Contractor's Information (If Applicable)
Name: S ,ol(f 1-k-o4;,ow S�Q4 \\o,,sio C U1, 2(Phone: ( =3__ —� o
Construction Supervisor's License #: (.. Sa yk d Expiration: 1 f"i I a,
Home Impr. Contractor License #: I I I g o S Expiration: ^i 1 1 )Z I
Stove Information
Type of Fuel (check all that apply): Wood 7/ Pellet Coal
Location: C c.s-cs- ; . . ,-_, Freestanding Insert
Manufacturer: Model:
--- ------- FOR BUILDING DEPARTMENT USE ONLY
o
Permit#13P-2oz(- Oc{`(�-7 j Date Applied: 03(o -2 2 1 Total all Fees: S t{o
Building Official: K m 'eA I<D5 5 Date Issued: '3-E 242.I
(Pt.)
Signature of Building Official: ��
The Commonwealth of Massachusetts
T , - dl Department of Industrial Accidents
v. , g 1 Congress Street,Suite 100
': 1 / Boston,MA 02114-2017w,e www.mass.gov/dia
tr Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): \\c.r-\-p\1,.) .\-q�S
Address: '3 3 (o C.-�\ �� -Q-3� --a �.-
City/State/Zip: '�',� hM�V:,-st\. 4) i Phone#: 1A( '3-7 y c 7
Are you an employer?Check the appropriate box: Type of project(required):
1.21.I am a employer with ' employees(full and/or part-time).* 7. [ J New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.(No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.]t
10 Q Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.0 I 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.
14.QOther w`mS. �� a�
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'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 most 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: A c.,,, -- V,c
Policy#or Self-ins.Lic.#: `eat',-,L c S h 3 —a - A Expiration Date: \1 .. o J
Job Site Address: 3- le, L s\ - Nsk- LF:k..G' ��-� City/State/Zip: (\oi -\P'4vc '1, 1v A o\n- '3
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$1,500.00
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.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 enalties r.,r:ju rat th information provided above is true and correct.
Signature: _,��-��� e A Date: I 9
Phone#: CI 3— )l( 3 c -C,
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: