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24D-040 (2) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i° 1 Congress Street Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AFS Cdb/a THE FIRE PLACE Address:106 STATE ROAD Cit !Statelip:WHATELY, MA 01093 Phone 4:413-397-3463 Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 10 4• ❑ I arm a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6 E]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 I 0.❑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.) ' e. 152,§l(4),and we have no employees. [No workers' 13.[]Other comp, insurance required.] *Arty 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 anew 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 iltc sub-contractors have employees,they must provide their workers'comp.policy number. I ant apt enlplover that is providing workers'compensation insurance for my en:plUees. Below is the policy and job site information. Insurance Company Name:MA RETAIL MERCHANTS WC GROUP INC Policy# or Self-ins. Lie. #:014005033601114 Expiration Date: 1-1-16 Job Site Address: �`� �/ ,; �c S't City/State/Zip: A/c r-- , n.P/c,r\ 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 S 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 S250.00 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 certif1under the pains and penalties ofperjury that the information provided above is true and correct Sit*_nature: 0Ckz., Date �— l� Phone : 413-397-3463 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.CityfTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Z-d 69K-L6£-E I.b aoeld end eyl . C Q of Northampton - Massachusetts �^? MAY �8 2915 ° lNT OF BUILDING INSPECTIONS , n, 'n Street • Municipal Building �`: pt;%cv, rj" "."..•• i� Northampton, MA 01060 B�,jY... 1�•1 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 LI INFORMATION 1. Name of Applicant: �i'C ! �'r� ��ex e� i)c ug/ccs Address: /O S7Q'7�� �' �/ri��c lyj,'nP --1i a9,-1elephone: 2. Owner of Property: ec V,4,-( / Address: / 93 �/�eS�cr7� /✓prl)laryf yV' Telephone: `/� 6'5-4 � 3. Status of Applicant: Owner Contractor 4, Type or Brand of Stove: If applicant is not the homeowner: Construction Supervisor's License Number `V6/ Expiration Date Home Improvement Contractor Registration Number > i�j y 7 7 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: �-� APPLICANT'S SIGNATURE DATE: ��� HOMEOWNER'S SIGNATURE APPROVED DATE: BUILDING OFFICIAL L'd eoeid e.I°d e41 193 PROSPECT ST BP-2015-1189 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-040 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-2015-1189 Project# JS-2015-002228 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BERNARDSTON FARMERS SUPPLY 99401 Lot Size(sq. ft.): 6882.48 Owner: TAGHAVI RAVYA zoning URB(100)/ Applicant: TAGHAVI RAVYA AT. 193 PROSPECT ST Applicant Address: Phone: Insurance: P O BOX 7 WC NORTHAMPTONMA01061-0007 ISSUED ON:512812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL HARMON ACCENTRA PELLET STOVE 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 SiEnature: FeeType• Date Paid: Amount: Building 5/28/2015 0:00:00 $25.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 193 PROSPECT ST BP-2015-1189 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-040 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catefzorv: woodstove BUILDING PERMIT Permit# BP-2015-1189 Pro iect# JS-2015-002228 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BERNARDSTON FARMERS SUPPLY 99401 Lot Size(sa. ft.): 6882.48 Owner: TAGHAVI RAVYA Zoning URB(100)/ Applicant. TAGHAVI RAVYA AT. 193 PROSPECT ST Applicant Address: Phone: Insurance: POBOX7 WC NORTHAMPTONMA01061-0007 ISSUED ON:512812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL HARMON ACCENTRA PELLET STOVE 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: L 1 Final: Smoke: Final: ��a/ 6 4C7 THIS PERMIT MAY BE REVO Y THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE TIO S. Certificate of Occupancy Signature: FeeType' Date Paid: Amount: Building 5/28/2015 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner