36-075 (9) 363 WESTHAMPTON RD BP-2016-1099
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 -075 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1099
Project# JS-2016-001321
Est. Cost: $3000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 93697.56 Owner: HOENER VIRGINIA
zonini4: Applicant: RICHARD SCOTT
AT. 363 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413) 478-6306 (�
HOLYOKEMA01040 ISSUED ON:3/15/2014 0:00:00
TO PERFORM THE FOLLOWING WORK:HEARTHSTONE WOOD 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 Signature:
FeeType: Date Paid: Amount:
Building 3/15/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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5ity of Northampton
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Massachusetts
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D P NT OF BUXLDING INSPECTIONS '..
v — 12 in Street • 'Municipal Building
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SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD,COAL, PELLET,CORN,STRAW OR SIMILAR STOVES, OR FIREPLACES
Check#
Please fill in all appropriate information
1. Name of Applicant : 1 Rv l w y a_ 4, (�
Address: �� ( ���?�,T'1���u Pt,x�r�v Telephone:
2. Owner of Property : nV 1 VZ<.
Address: 5 t) t Telephone:
3. Status of Applicant : Owner il�Contractor
4. Type or Brand of Stove : e 11�_lis 10 4,� Ljaob
5. Estimated Cost : T 3 d J Z)
If applicant is not the homeowner::
Contractor name � r
Construction Supervisor's License Number // Expiration Date "
Home Improvement Contractor Registration Number. G C� �� Expiration Date '7L
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
6. Certification: I hearby certify that the information contained herein is true and accurate to the best of my
knowledge.
DATE: 7 - APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
I
I
i
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
W Office of In vestigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers
Applicant Information ` a Please Print Legibly
Name (Business/Organization/Individual): `�- �(� l
Address: �12-- 6), Pr r-C3) y�
City/State/Zip: �..� r� (✓ Phone#3 E " 6 �e �6
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4• ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.[d,,�am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
shipand have no employees These sub-contractors have
8. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.:
9. ❑ Building addition
comp.[No workers' comp. insurance p•
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 13.❑ Other
employees. [No workers'
comp. insurance required.]
Any applicant that checks box 41 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. #: lExpiration Date:
_)
Job Site Address: C'� !(� ' City/State/Zip: fl 6n
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 certify under the pains and penal ies perjury that the information provided above is true and correct.
Si ature: / Date: /
Phone#:
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#•