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17A-152 Olde Hadleigh Hearth & Patio <info @oldehadleigh.com> WC Affadavitt & Liscense Info October 11, 2012 1:23:09 PM EDT "eriks54 @comcast.net" <eriks54 @comcast.net> Olde Hadleigh Hearth & Patio <info @oldehadleigh.com> 2 Attachments, 981 KB The Commonwealth of Massachusetts I runt rurrn Department oflndustrial Accidents Office of Investigations i 7 1 Congress Street, Suite 100 7 ;a Boston, MA 02114 -2017 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Informations Please Print Legibly Name (Business/Organization/Individual): Olde Hadleigh Hearth & Home Center, Inc. Address;119 Willimansett Street City /State /Zip: South Hadley, MA 01075 Phone #:4131538 -9845 Are you an employer? Check the appropriate box: Type of project (required): SI I am a employer with 8 4. ❑ I am a general contractor and I employees (full and /or part - time).* have hired the sub- contractors ❑ New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees 'These sub- contractors have g, ❑ Demolition working for the in any capacity. employees and have. workers' ❑ (No workers' comp. insurance comp. insurance.[ 9. Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. [1 I am homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. No workers' con right of exemption per MGL ❑ p• i p 1. Roof repairs insurance required.] I. c. 152, §1(4), and we have no 13. © C)ther Install wood stove 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. I lomeowners 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers Insurance Home Improvement Contractor's Liscense #148198 Policy # or Self -ins. Lie. # B5197B81 Expiration Date: 7!12/2013 Job Site Address: CityiState /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 tine 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 line 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. 1 do hereby certify under thee-paaiin-s and penalties of perjuty that the information provided above is true and correct. tionatnr. • I /�` `/ "1`� t �....� 8/10/2012 r, " •49I j • . * 4 ‘): • • • 1 - .‘ • r A ^ ji 4 . O ye i I • SOIS r - y of Northampton RECEIVED /� Massachusetts .T • d(_ OC � D. PAR NT OF BUILDING INSPECTIONS ' '2 in Street • Municipal Building ay Northampton, MA 01060 � D'E NORTHAMPTON, MA 0 060 NS SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS Permit Fee: $25.00 Check # S9 C PLEASE E OR PRINT ALL INFO MATION PROPERTY ADDRESS .5 L 1 fOX Vetrut3 R & 1. Name of Applicant: FC wJ , , AS(° & � (� Address: S 1 ) ( ` u V C \, —(� Telephone: U -7 - .3 ‘ 1 Owner of Property: E Q v 'l et,s b'` �^� Address: C9 %-6X kttC 'K � L Telephone:CL(13) J D€ 3 v3 k 3. Status of Applicant: Owner Contractor 4. Type or Brand of Stove: Vtro IAK ` CT■ .S y 0 h -46 t e r Contractor's Name: YZQ 4c' .4(. `"e't_ , t- ( -,' `'`e, , Contractor's Address: oct W . + \c U.( '`5 24 51.14 -1 ey A 0107s � s.3) c? S4'{J f Contractor's Phone: � 3) Construction Supervisor's License Number: 9 f 7 7r LI Expiration Date: 4 1? O/1 3 Home Improvement Contractor Registration Number: /90 9 £ Expiration Date: 9/j3/) All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 5. Certification: I hereby certify that the information contained herein is true • , curate to the best of my knowledge. DATE: / 2, P T' SIGNATURE S� _ 40011P 1111114k DAT / �A PLICAN S SIGN `■ V, DATE:! x/ 2 --HOMEOWNER'S SIGNATURE V 1 %1. L-3 APPROVED DATE: BUILDING OFFICIAL 54 FOX FARMS RD BP- 2013 -0483 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 152 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit # B P- 2013 -0483 Project # JS- 2013- 000769 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784 Lot Size(sq. ft.): 15681.60 Owner: STENSON ERIK L & JANE R EVANS Zoning: URA(100)/ Applicant: STENSON ERIK L & JANE R EVANS AT: 54 FOX FARMS RD Applicant Address: Phone: Insurance: 54 FOX FARMS RD (413) 584 -3139 0 WC FLORENCEMA01062 ISSUED ON:10/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VERMONT CASTINGS MONTPELIER 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: 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 10/24/2012 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner