25C-263 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations 600 Washington Street
Boston, MA 02111
www.nass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
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):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
em am (full and/or part- time).* have hired the sub - contractors
2. [ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. n Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] _ 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. repairs or additions
3. E] I am a homeowner doing all work ❑ Plumbing P.
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*.Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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 nacre 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer if under the pains an penalties of perjury that the information provided above is true and correct.
Simnature: �v' v�Z Date: / — C / IO
Phone #: � .P1 I
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 #:
Version1.7 Commercial Building Permit May 15, 2000
Departrnel t use,ar ly
City of Northampton s o Permit
B tiding Department curb GuffDriveway Perm
1 ° t -. 12 Main Street S
ewer` /SepticAuaifabihty
Room 100 WaterllMlell AVallabllity:
C 6 tile rt h mpton, MA 01060 Two Sets of Structural Plays
V ph o 4 j; -58 -1240 Fax 413- 587 -1272 PIot/Site Pl
T. � ,oeU Other S ecifiy +.
A L A CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
/ Zone Overlay District
. _. �_. .._ ----, _ ._ _._. . ,,. , ___ _Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
H t - vi-A? - ,� 4 __ _ _ __ �_- . _ _ ._. _ 1 c ld (_.
Name (Print) Current Mailing Address:
Signature ■ \ 0--4 ,_ t. • _
Telephone
2.2 Authorized Agent
Name (Print) Current Mailing Address
Signature .. .,4., " :.-c--- --1 - '7
�' Telephone
SECTION 3 ESTIMATED C STRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ? (a) Building Permit Fee
2. Electrical '- -- - _ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing _. -__. _ --- Building Building Permit Fee
4. Mechanical (HVAC) _ __ __, ..._.__ ..__... ..._...._.
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number / 4
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
19 OLD FERRY RD BP- 2013 -0260
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 263 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0260
Project # JS- 2013- 000423
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: QUINLAN BUILDERS 011289
Lot Size(sq. ft.): 142441.20 Owner: BOBALA JOHN J & KAREN A
Zoning: SC(99)/URB(2)/ Applicant: QUINLAN BUILDERS
AT: 19 OLD FERRY RD
Applicant Address: Phone: Insurance:
9 HILLSIDE DR (413) 549 -5474 0
HADLEYMA01035 ISSUED ON:9/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE METAL LEAN TO BARN ROOF
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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 9/7/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner