23B-054 (3) 40 BERKSHIRE TER BP-2018-1051
GIs u: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-054 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-2018-1051
Project# JS-2018-001902
Est.Cost:$3400.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GrouP7 RICHARD SCOTT 83108
Lot Size(su. R): 10890.00 Owner. ERBA MARK
Zoning: URB(100)/ Applicant: RICHARD SCOTT
AT: 40 BERKSHIRE TER
ApplicantAddress: Phone: Insurance:
20 BULLARD AVE (413) 478-6306 O
HOLYOKEMA01040 ISSUED ON.411812018 0:00:00
TO PERFORM THE FOLLOWING WORK.QUADRA FIRE 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 ft 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 OCCugancv signature:
FeeTvpe: Date Paid: Amount:
Building 4/18/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
e
City of Northampton
Massachusetts
N ® Z
DEPABs OF BUILDING INSPECTIONS
Be
212 in street • awn 010 Building Su`
\ NoiNamptoq !P01060 Sy^. .�140C
ps�
APR 13 106-1
psar or su�rnvo wwFsnons
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
WOOD,COAL, PELLET,CORN,STRAW OR SIMILAR STOVES,OR FIREPLACES
Check#
Please fill inallappropna�I 1in/f�o/rj��att n .L
I. Nameof APp:icant:// frY% P� �Y—�r V't-W �W f/-7
Address: 7 LJ /1�U;-LSU /�-� / 2J Telephone:-T�'2"63/ -Ojzs
2. Owner of Property/:y,,{� �r2 C7i17Co L
Address.
3. Status of Applicant: `- Owner Contractor / p
4, Type or Brand of Stove
//
5. UL Listing : ' b ii 7 1 � � L Z, �f��', S C 1 - d b
6. Estimated Cost: *3 Ll o D
7. Email :
If applicant is not the homeowner:'.
Contractor name R, � �LGrt Email :
Construction Supervisor's License Number 6 83 ��/� / Expiration Date 6 /
Home Improvement Contractor Registration Number 0 6 Z y Expiration Date V?L
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
8. Certification: I hearby certify that the information contained herein is true and accurate to the best of my
knowledge�l ,, � � �
DATE: (/ APPLICANT'S SIGNATURE ! \ t
DATE:X7//3�//Ct HOMEOWNER'S SIGNATURE
APPROVE/D
DATE:-GZ- -C�I-LJBUILDING OFFICI V �
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
IF www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name (Business/OrganizatioNlndividual): Richard Scott
Address: 20 Bullard Avenue
City/State/Zip: Holyoke, MA 01040 Phone #: (413) 533-6340
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with_ 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
2.❑X I 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'
insurance< 9. E] Building addition
comp.[No workers' comp. insurance P.
required] 5. E] We are a corporation and its ME Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their ILD Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 [:1 Roof repairs
insurance required.] t a152, §1(4),and we have no 13.�] Other Stove Install
employees. [No workers'
comp. insurance required.]
-Any appliedin that checks box#1 must also fill out the section below showing their workerscompensation policy Infmmatlon.
I
Homeowners who submit this affidavit indicating they are doing all work and then Lure outside contractors must submit anew affidavit indicating such.
l(na eaetm,that check this be.must attached an additional sheet showing the name of the sub-conmators end smte whmber or not those entities have
employees. If the subcontractors have employees,they must provide their w.,kau'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: SH1 �.�I Ci /State/Zi ' LO
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 ofa
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pains andpercal perjury that the information provided above is true and correct.
S-e at re' 1�14 �a Date'
L / z
Phoned: (413) 533-6340
Official use only. Donal write in this area,to be completed by city or town ofciaL
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#: