23C-032 BP-2023-1581
620 RIVERSIDE DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23C-032-001 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-2023-1581 PERMISSION IS HEREBY GRANTED TO:
Project# PELLET STOVE 2023 Contractor: License:
Est. Cost:
Const.Class: Exis.Date:
Use Group: Owner: M DIVOLL MARK A& KRISTIN
Lot Size (sq.ft.)
Zoning: GI/WP Applicant: M DIVOLL MARK A&KRISTIN
Applicant Address Phone: Insurance:
620 RIVERSIDE DR
FLORENCE, MA 01062
ISSUED ON: 11/09/2023
TO PERFORM THE FOLLOWING WORK:
INSTALL NEW 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:
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:
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it
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATI•N
Property Information
Owners Name: i /Vf}M . A. Kio S T nA* / V I, JivoL L
Address: kb f I V E/LS /. _ -ie ' � L 0l`2 L IVC6 44 A-, n I t)607.
(No.) (Street Address)
Phone: 443 ; ' ? Cell: Lie 'O'd%mail: rA(Mid Gac(a� j Me L p Goon
Owners Signature:X�`"<(-4},,,�r� ,6AJDate: / ( — �,3
Contractor's Information (If Applicable)
Name: Phone:
Construction Supervisor's License #: Expiration:
Home Impr. Contractor License #: Expiration:
Stove Information
Type of Fuel (check all that apply): Wood Pellet i Coal
Location: 4.44 &-ems_ &A-�C c
reestanding / Insert
Manufacturer: /--pcIKrv11 / /� Model: ISOLL{TC 3 'elief- S��i/ '
r _FOR BUILDING DEPARTMENT USE ONLY-----------__ _____;_
Permit# g ;13 -/y g/ Date Applied: Total all Fees: $ 110 C rigi:21
Building Official: gEu,,,) ' i- 3 Date Issued: I t- q.2.02_5
(Pt) ////
Signature of Building Official:
The Commonwealth of Massachusetts
}- ~ ' 1, Department of Industrial Accidents
ilia vim 1 Congress Street, Suite 100
.t�U, ' 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/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑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. ❑Remodeling
y capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3. am a homeowner doing all work myself.[No workers'comp.insurance required.]t I t
10 ❑Building addition
4.01 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
5.171 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof 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.❑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 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: 6,..1) i/j jZ S p(24 City/State/Zip: 0/ 06 A.
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 and the pains and penalties of perjury that the information provided above is true and correct.
ignature)1 01,7- 11 ' 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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
City of Northampton
Massachusetts ?��' �''c{t
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ��, .fib
L <r� Northampton, MA 01060 r j116
•
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
•
(insert full legal name), born _ (insert
non , day, year), herebydepose 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 license 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 , 20A
Signature)