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29-308 (7) The Commonwealth of Massachusetts -- --- Department of Industrial Accidents ,l Ft Office of Investigations t ; 1 Congress Street, Suite 100 , Boston,MA 02114-2017 k_ www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (t;usincss/Organization/Individtizil): BERNARDSTON FARMERS SUPPLY Address:43 RIVER STREET City/State/Zip: BERNARDSTON MA 01337 Phone #:413-648-9311 Are you an employer? Check the appropriate box: Type of project(required): 1.R I am a employer with 10 _ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 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. ❑ Demolition working for me in any capacity. employees and have workers' ❑ 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. Plumbing repairs or additions 3.❑ l am a homeowner doin��all work I myself. No workers' com�. right of exemption per MGL } [ 1 12.0 Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp. insurance required.] " Any applicant that checks boy#1 must also fill out the section bclott showing their workers*compensation policy information. I lomcomiers Who submit this af7itlat°it indieatingthey are doing all work and then hire outside contractors must submit a nett affidavit indicatilla 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 hat r cmplotees. ll the sub-contactors have employees,then must provide their workers'comp.polic)'number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the polio'and joh site hi f ormation. Insurance Company Name: PEERLESS INSURANCE Policv # or Self-ins. Lic. #:WC8165644 Expiration Date: 7/1/15 Job Site Address: '3+ k!reh!'oole `Z)r 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 tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5250.00 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 tlo hereby certy'1-•u'nder the pains and en/alltties of'perjury that the information provided above is true and correct. Siunature: Cam / d� Date: Phone 9: Offrc•ial ttse only. Do not write in this area,to be completed by city or town official. Citv 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#: 1J11 W` I - o rthamp '-= I3o ton OCT Massachusetts R �j g QE BVIIsDSNG Xff5rzC==S Street • Municipal Building dingy 9&Gas Inspections xortba=ton, mA 0106D :.=- Northam ton, MA pi060 = SINGLE oR TWO PAMILV SnLin FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES. OR FIREPLACE INSERTS Permit Fee: $25.00 Check PLEASEt TYPE OR PRINT ALL INFORMATION 1. Name of Applicant Address: I7rcI l i 15f r =;,h /�`I 1•� Telephone: 2_ Owner of Properly: /n�� Address:_3 �� &L r e b r o c fie 71 r Telephone; V/,�r U 3 3_ Status ofApplicani Owner Contractor d. Type or Brand of Stove: I4)',9 Z2 "1 A t-j If applicant is not the homeowner Construction Supervisor's License Number �/' � �� Expiration Date Home Improvement Contractor Registration Number Expiration Date 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 and accurate:to the best of my knowledge. DATE; 104 /"/ ` APPLICANT'S SIGNATURE DATE: HOMEOWNER'S SIGNATURE APPROVED DATE- BUILDING OFFICIAL 382 ACREBROOK DR BP-2015-0419 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-307 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# BP-2015-0419 Project# JS-2015-000748 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BERNARDSTON FARMERS SUPPLY 99401 Lot Size(sq. ft.): 44300.52 Owner: NATALE JAMES F JR&CLAUDIA J Zoning: Applicant: BERNARDSTON FARMERS SUPPLY AT. 382 ACREBROOK DR Applicant Address: Phone: Insurance: 43 RIVER ST (413)648-9311 O WC BERNARDSTONMA01337 ISSUED ON:1011012014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL MARMAN PGIA 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 10/10/2014 0:00:00 $25.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner