23C-066 (6) 93 BLISS ST BP-2021-1438
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23C-066 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-2021-1438
Project# JS-2021-002393
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NEW ENGLAND CHIMNEY SWEEPS & MASONRY INC094022
Lot Size(sq.ft.): 80019.72 Owner: CLOONEY DAVID
Zoning: URA(100)/WSP(100)/ Applicant: NEW ENGLAND CHIMNEY SWEEPS & MASONRY INC
AT: 93 BLISS ST
Applicant Address: Phone: Insurance:
535 COLLEGE HWY (413) 568-6488 WC
SOUTHWICKMA01077 ISSUED ON:6/2/2021 0:00:00
TO PERFORM THE FOLLOWING WORK: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.
4 • • , >2 ckAil
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/2/20210:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
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v`�' DEPARTMENT OF BUILDING INSPE ONE "4 '''
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212 Main Street • Municipal Builai • / 0
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APPLICATION FOR SOLID FUEL APPLIANCE IN ,;. ._ ' TION
Property Information
Owners Name: Davi 0 a y, d A-vy-)62. r C° 16 U h,Q1
Address: 93 6 1 ( -i Y\oYQ r CQ
(No.) (Street Address)
Phone:til 3 - 3(4 5-'1133 Cell: Email:af,laor. kky)h.e e 5 i ,a,L. ccM-
Owners Signature: (51 QQ 4v C,C Date: '5/a 5/coal
Contractor's Information (If Applicable)
►1lasonrA ZiL.
Name: AP(4) E.os land (''hi kr,ns SLe,v s + Phone: L l 3 -'S(DS-69 Li SS
Construction Supervisor's License #: ( S -U g Li Oa a Expiration: i al A 9 (au,. .I
Home Impr. Contractor License #: 1,19 3 Expiration: 3/9 12c.,D,3
Stove Information
Type of Fuel (check all that a ply): Wood X Pellet Coal
Location: i- V i he Ro r-, f��,n; Freestanding )( Insert
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Manufacturer: �oy Yr,o n-4u -%n 5 Model: Din-H sS F l.a_'.kxt
---_------_-_----------FOR BUILDING DEPARTMENT USE ONLY-------------___-_--_-_-_-
Permit# 19/--2/'/43 Date Applied: Total all Fees: $ 4'C' (%+ '&j` '6
Building Official: Evl,.) 1 ,55 Date Issued: G- Z- 20ZI
(Print) !/Signature of Building Official:
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�"_" The Comnwnwealth of Massachusetts
'�f Department of Industrial Accidents
i
�` I Congress Street, Suite 100
Boston, MA 02114-2017
„�., rvtvw ntass.gov/dia
Workers'Compensation ►, ,.cp Affirj:rvih. Ruitders/( ontractors/Electricians/Plumbers.
TO BI New England Chimney Sweeps Y.
Applicant Information And Masonry Inc. Please Print Legibly
Name(Business/Organization/Individual), P. O. Box 135
Southwick, MA 01077
Address: 413-568-6488
City/State/Zip: S-,t,1-huj t L,I(.. t1(11A 0107'1 Phone#: t U3- 5(o - 64 S-S
Arc you an employer?Check the appropriate box:
Type of project(required):
1)141 I am a employer with LI employees(full and/or part-time)' 7. 0 New construction
2 I am a sole proprietor or partnership and have no employees working for me in
b. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. 0 Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.CI Plumbing repairs or additions
5.0 I ant a general contractor and I have hired the sub-contractors listed ou the attached sheet
These sub-contractors have employees and have workers'comp.insurance.: 13._Roof repairs 4
6.0 We are a corporation and its officers have exercised their right of exemption per WI.c 14.'�Othei j 0 SkLI Z( (2icx'cj
152.§1(4),and we have no employees.[No workers'comp.insurance required.) 3.4 j- -- -4- e t taS' Ka-
+ ��
'Any applicant that checks box P1 must also till out the section below showing their workers'compensation policy infomArratio7n.
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: —TraU. -Etr (4)ps1 rtoU'L Co S t 14-
J
Policy n or Self-ins.Lie. #: ` 1 P c7 u t5 A E 0 9 3 ( 4 LID, Expiration Date: 31(S i ,.r,Zuaq... _
Job Site Address: ` 1 3 61 55 s 4 City/StateiZip: - (01(..f1I'1tz„ l4 O(D( .-;/ _
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 SI,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 penalties of perjury that the information provided above is true and correct
Signature: ---6 2A.t.", JC_ W''�?.t e '-- Date: 'S/.95l 2 G;./
Phone#:L.1(3 -51 -L945ss
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.Cityll'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
1'