25C-053 (19) BP-2022-1431
51 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-053-001 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-2022-1431 PERMISSION IS HEREBY GRANTED TO:
Project# WOOD STOVE Contractor: License:
Est. Cost: 103548
Const.Class: Exp.Date: 10/01/2023
Use Group: Owner: MEERBERGEN CHADD P&NORA L KENNEDY
Lot Size (sq.ft.)
Zoning: URB Applicant: CHADD MEERBERGEN
Applicant Address Phone: Insurance:
51 LINCOLN AVE (508)221-4609
NORTHAMPTON, MA 01060
ISSUED ON: 11/08/2022
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
l
f b CS-111 •
I ,
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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City of Northampton
.1 Massachusetts
ire A /1 - * ;c
1.r- li: ,K l y DEPARTMENT OF BUILDING INSP CTIOSI�/
C. �' 212 Main Street • Municipal B(iildinq ' 1s
kj Northampton, MA 010�'6,oT 1 s'r: S'.
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APPLICATION FOR SOLID FUEL APPLIANCE S ALLATION
t6 i-' --/413)
Property Information
Owners Name: A/O' !44 kEvfvc,D yam- (-#4.L) 44�ER-gt L E.'7
Address: 5 / L,/NLO L Al 4ve. No p_7-1.40 YiA) 7 10- 1/0 0
(No.) / (Street Address)
Phone: �`f��7l5-Zd 20 Ce Email: Flora�c#ii ccn/7cdy <j�n :( 4e,../
Owners Signature: �i
ili2l Date:Contractor's Informatioplic le)
Name: CA444® meez..4 4e-E0-) Phone: �S' off) L 2f - y_9
Construction Supervisor's License #: ' /U 5`/ 1 Expiration: l01///�3
Home Impr. Contractor License #: Expiration:
Stove Information
Type of Fuel (check all that apply): Wood Pellet Coal
Location: Cev,,a Freestanding / Insert
Manufacturer: Ai riot$7oc-K Soff J fir 6e • Model: r_,ys-ropic 50 A,s raN c-_ w() ,0 5mOc-
-- FOR BUILDING DEPARTMENT USE ONLY
Permit# Date Applied: Total all Fees: $ 4/0 ,M 5g17
Building Official: gLev j►...) /doss Date Issued: // 6-Z D Z Z
(Print)
Signature of Building Official: �"
The Commonwealth of Massachusetts
l Department of Industrial Accidents
1 Congress Street,Suite 100
r Boston,MA 02114-2017
`b_ www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibly
Name{Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I al a employer with employees(full and/or part-time).* 7. ❑New construction
2. I/am a sole proprietor or partnership and have no employees working for me in 8. Ei Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
4.E 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.D Electrical repairs or additions
proprietors with no employees.
12.El Plumbing repairs or additions
50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13, p
❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c 14.DOther
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 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 certtfy and r the p ins and enalties of per'illy that the information provided above is true d correct.
Sietlature: ). �f Date: 7/ // 2l�Z � Z
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#: