11C-043 City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 5-0 .3e114ld-ch" '<4
The debris will be transported by: ��'`/
The debris will be received by: TOGS ,I- stcfeyl
Building permit number:
Name of Permit ApplicantG��f
Date gnature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
a
Office of Investigations
d 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f ] At-
Address: Print Legibly
Name (Business/Organization/Individual): ( Gt%l' —C '��L� u���
Address: 1i2 30 X )a�L(
City/State/Zip: Phone #:
Are you an employer? Check the 4propriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
ployees (full and/or part-time).* have hired the sub-contractors 6. ❑ 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 me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp, insurance.T
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13 Other_{� ,jf cz, x_
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:.` r4-r1 q City/State/Zip:kee.)), ,44±
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 certi under the��jjains and penalties of perjury that the information provided above is true and correct.
Si ature: � �?✓l�2' Date: ,11 GI
Phone #• 340
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#:
City of Northampton
-�
s
Massachusetts
TMENT OF BUILDING INSPECTIONS z
Pd 21 in Street • Municipal Building
Northampton, MA 01060
2014
i _f
r; pections
SINGLE SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check #
/� �, `/
PLEASE TYPE OR PRINT ALL INFORMATION �^`
1. Name of Applicant: lbr) / ' t(�•1 �l bo� �YhT e A(qWe1 .�C/``I/��
Address: r � � ,(��dVNS iy �1e 6 Telephone: YQ` N j
2. Q�ddress:Owner of Property:
TJ
1 VI�C I �i etrl 01 6 �elephone:
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: 1 ' M er WI P No►.�� �-'�L--
rr �
If applicant is not the homeowner: d/
Construction Supervlsces License Number. Expiration Date 05/9 1, 7
Home Improvement Contractor Registration Number 17$ '7 ) Expiration Date U ;/
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. j
DATE: ` APPLICANT'S SIGNATURE
DATE: �� ��� HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
50 BERNACHE ST BP-2015-0664
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-043 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-2015-0664
Project# JS-2015-001276
Est.Cost:
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CORY J MCGILL 107568
Lot Size(sq. ft.): 19297.08 Owner: MIENTKA SINGWEN R
zoning: URA(100)/ Applicant: CORY J MCGILL
AT. 50 BERNACHE ST
Applicant Address: Phone: Insurance:
P O BOX 1054 (413) 340-1399 ()
WILLIAMSBURGMA01096 ISSUED ON:1211612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL TIMBERWOLF 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 12/16/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
NEENEENOMW