39A-065 (3) Office of Ccnsumer Affairs and Business Regulation
10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home I)nprovement Contractor Registration
Registration: 148198
Type: Private Corporation
Expiration: 9113/2015 Tril 2,13955
OLDS HADLEIGH HEARTH & HOME CE-NT
MATTHEW COX
119 VVILLIMANSETT STRETT RT 33
S. HADLEY, MA 01075
Update Address and return card. Mark reason lor Qlmw,
Address F
Renewal [7] Employment 1,i1 t
A 1 20M-05/11
�,Tlle�OW111011100(71111 /.'Cw/c',oek„)alrj
Office of Consumer Affairs& Business Regulation License or registration valid for individul use oniy
before the expiration date, If found return to:
qOME IMPROVEMENT CONTRACTOR egistratlon: 148198 rype: Office of Consumer Affairs and Business Regulation
,Expiration: 9113/2015 Private 'orporatic,
10 Park Plaza-Suite 5170
P '
Boston,MA 02116
-f-1E HADLEIGH HEARTH& HOME CENTER, INC.
ATTF i:-:W COX
VVILLIMANSETT STRETT RT 3
HADLEY, MA 01075 Undersecrel iry Not vidid without signature
Massachusetts - Department of Public
Board of Building Reoulations and Standnrui ,”,
Supervisor S'l-w6 -olt�
c,ewnse ; CSS- L 878-4
�j
............
MATTHEW Cox,
54 ILAD LEY SITIE N
SOUTH HADLEV
Ex P1
04/28/'201 ,'-)
Commissioner
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston MA 02114-2017
`y 1� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/:Plumbers
Applicant Information 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 #:413/538-9845
Are you an employer? Check the appropriate box: Type of project(required):
1.2 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 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'
[No workers' comp. insurance comp. insurance.$ 9. E] Building addition
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or addition;
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13 ❑ Other 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,
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:Travelers Insurance Home Improvement Contractor's Liscense#148198
Policy #or Self-ins. Lic. #:IEUB5197B81b Expiration Date: 7/12/2015
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 tine
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 pains and enalties o Aver'=that the in ornurtion provided above i true and correct.
J
Si mature: Date -
Phone#:538-9845 CS SL#9878
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#:
^Oi. of Northampton
�I Massachusetts �:
i
KC
20tQ IU"
DEPA�2TME OF BUILDING INSPECTIONS
{ 21 ain Street • Municipal Building ily
�rgpeC1t01"'� rthampton, MA 01060
�c-
_._- Electric, P°iurrioi��� VA 01060
N-)r thli -
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#
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name cf Applicant: i �, 1. Vj (; r�
Address: LkAPTO -T-Cl '„ Telephone:
2. Owner of Property: --J-A�M � , /c� T I I- L-- 4� G6- ° -v L I
Address: (0 d A I�l?7 0 IV —F Telephone: 13
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: —.J o i- F T a EAST ( Nf
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 trug a�d-accurate to the best
of my knowledge.
DATE: I { ! 1 1 APPLICANT'S SIGNATUFZE
DATE: HOMEOWNER'S SIGNATUI`k�
APPROVED
DATE: BUILDING OFFICIAL
10 HAMPTON TER BP-2015-0657
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A-065 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-2015-0657
Protect# JS-2015-001257
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sg. ft.): 58806.00 Owner: SARIGIANIDES JAMES
Zoning: URB(51)/SC(49) Applicant. SARIGIANIDES JAMES
AT. 10 HAMPTON TER
Applicant Address: Phone: Insurance:
10 HAMPTON TERR (413) 727-8076 WC
NORTHAMPTON MA01 060 ISSUED ON.1211212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL JOTUL F400 CASTINE 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 12/12/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner