10D-005 (3) BP-2021-2195
81 WATER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
l OD-005-001 CITY OF NORTHAMPTON
Permit: Solid Fuel
Appliance
PERSON', CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
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Permit# BP-2021-2195 PERMISSIONIS HEREBY GRANTED TO:
Project# PELLET STOVE Contractor: License:
Est.Cost: SANDRI ENERGY LLC 06821
Const.Class: Exp.Date:03/14/2022
Use Group: Owner: WILLIAMS JEANETTE S TRUSTEE
Lot Size(sq.ft.)
Zoning: URB Applicant: SANDRI ENERGY LLC
Applicant Address Phone: Insurance:
400 Chapman St (413)772-2121 qwc4001814
GREENFIELD, MA 01302
ISSUED ON:11/17/2D21
TO PERFORM THE FOLLOWING WORK:
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 CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
, • r
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of Northimp
, RECEIVE '
assachuset r-----
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la n DEPAR TbENT OF BUILDING iNSPECTIONV V 1 5 2021
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212 Main Street • MunIcipa?. Du4ding
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Northampton, MA 01 60 1 N7-61‘
DEPT.OF BUILDING INSPECTIONS_ i
NORTHAMP1ON.MA 01060 ...j
APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION
Property Information
Owners Name: ,-„it,(_t tic-ti_c. i-L....
Address: ' 7?_ )(Litt (5-tree,"
(No.) (Street Address)
Phone: -/ i 4 Cell: Email: 1,-, ri ':0...;!I lo I I).5 (_.
Owners Signature: ,--Y -,--,--7- -.'
,,,z-Ze-to---,-- Date: /7- '/ -..2 /
z
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Contractor's Information (If Applicable) _
Name: - ' ,, , /it- i i-j Phone: r" ' •i 7,-,? &/,:.? /
Construction Supervisor's License #: 425 -,:'''''.- S'A / Expiration:
Home Impr, Contractor License #: / ?4 / 9 c,d Expiration: -
Stove Information
Type of Fuel (check all that apply): Wood Pellet X Coal
Location: PL-t -lic Freestanding A Insert
Manufacturer: -* i,j i Li i , t, v Model:
---------------------FOR BUILDING DEPARTMENT USE ONLY---------------------
Petinit# /, 79/ Date Applied: Total all Fees: S 110 CC-
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Building Official: C..=Uip.-s /Z-, Date Issued: I I- it, ZOZI
(Print.) /7:71/
Signature of Building Official: /6._ _
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v u :r a 2`w{ I i
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The Commonwealth of Massachusetts
Department of Industrial Accidents
d 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ( Please Priut Legibly
Name(Business/Organization/Individual): cri a r5 b,
Address: �{( L'h< rr?Cj n Si J
City/State/Zip: 6-4r.eer1,i e c /t-/" OW Phone#: 77
Are you an employer?Check the appropriate box: Type of project(required):
1.12 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working forme in 8. p Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing ail work myself.(No workers'comp.insurance required.]t
10 El 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,nR00f repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other / � ��
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 hue 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: ill-)l'e1e to rl Ct-47 S-ct-r4-n ce £omPCl-1L-y
Policy#or Self-ins.Lic.#: £l )t?. O/ 77 y Expiration Date: ? w/ /c3 a
Job Site Address: S GIJGt e-Y S1 - City/State/Zip: Leeds ; It l 6/Gv 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 penalties of perjury that the information provided above is true and correct
Signature: 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#: