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23D-066 (7) BP-2022-0121 4 WARNER ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23D-066-001 CITY OF NORTHAMPTON Permit: Solid Fuel Appliance PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0121 PERMISSION IS HEREBY GRANTED TO: Project# WOODSTOVE Contractor: License: Est. Cost: Const.Class: Exp.Date: Use Group: Owner: NU-WAY HOMES INC Lot Size (sq.ft.) Zoning: URB Applicant: INC NU-WAY HOMES Applicant Address Phone: Insurance: 10 WHITE ST EAST LONGMEADOW, MA 01028 ISSUED ON:02/08/2022 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON U PON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: .11 . Ts'I • Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner City of Northampton 11 ' "`A /,_ ott: Massachusett >J� �. ti V 4( „`'� ' DEPARTMENT OF BUILDING'' INSPECTIONS ' 1 1-1 4 \ao ..t, 212 Main Street • Municipal Buildi�0 „1 5 aj Northampton, MA 01060 �l oV� , ;,r,,;,,.-�4 1\1"„ 0'` sY 3n APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: NU - (4) /-in-fri eS -1732<< Address: V wM" �i. (No.) (Lp 3 J (Street Address) Phone: Cell: D00' Email: ✓11 earl c ies6c E 44,2-cam Owners Signature: "70( Date:.:;2/7/.6 Contractor's Information (IfApplicable) Name: Phone: Construction Supervisor's License #: Expiration: Home Impr. Contractor License #: Expiration: Stove Information Type of Fuel (check all that apply): Wood Pellet Coal Location: 1(305e.4n&.y7` Freestanding !/ Insert Manufacturer: t4)00d r�,,,t Model: FOR BUILDING DEPARTMENT USE ONLY Permit# eO- ,2.2-- /,1/ Date Applied: • Total all Fees: S WU C4,#i/P i l Building Official: Date Issued: a•AV9a (Print) Signature of Building Official: 2 ,c-y..4„ty The Commonwealth of Massachusetts It Department of Industrial Accidents 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 Print Legibly Name(Business/Organization/IndividuaI): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 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 for me in 8. ID Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. El Demolition 4.p 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.Q Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.O 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 him 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.#: Expiration Date:_ Job Site Address: City/State/Zip: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton oa.�aa" '` Massachusetts �?' `';tr { ` DEPARTMENT OF BUILDING INSPECTIONS ju 212 Main Street • Municipal Building Northampton, MA 01060 s4 anll 9 )/11:::/ / ////14- HOMEO RS'EXEMPTION ELIGIBILITY AFFIDAVIT I, .(insert full legal name), born — (insert month, day,year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision Iicense and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature)