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37-008 (7) BP-► 022-1390 770 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 37-008-001 CITY OF NORTHAMPTON Permit: Solid Fuel Appliance PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1390 PERMISSION IS HEREBY GRANT S D TO: Project# WOOD STOVE Contractor: License: Est. Cost: NORA WINE CSSL-1061'9 Const.Class: Exp.Date: 08/24/2024 Use Group: Owner: HIJAB CABLE, LAYLA Lot Size (sq.ft.) MCKENNEY HEARTH&HOME/MC :NNEY Zoning: SR/WSP Applicant: ELECTRICAL CO INC Applicant Address P one: Insurance: 100 NORTHAMPTON ST (413)586-5351 XWO2257872259 HOLYOKE, MA 01040 ISSUED ON:10/26/2022 TO PERFORM THE FOLLOWING WORK: WOOD STOVE INSERT 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: • .>ZR CIAD`157 Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner - '- City of Northampton -CHA).gy '4 __VVV �. Massachusetts 4,V ''''Pe Aliglr t •=,AI2 OF BUILDING INSPECTIONS yi ", rip � 12 n Street • Municipal Building vti a \ T 2 2022 Northampton, MA 01060 �j1yY �� WEPT.OF GUII.DIN, n'OriTHAMPTO IMA OE060 NS 3 7 -GO, APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: Lak C-\e Address:"14O -FI 04�N 6). (No.) (Street Address) Phone:l►-4-.15 i g. 09 g3 Cell: Email: • Owners Signature: Date: /h113'22 Contractor's Information (If Applicable) Name: Iv(114. kl Phone: (II 3. 21..S5 51 Construction Supervisor's License #: (ESL- ( cX cl Expiration: S4v9.-f Home Impr. Contractor License #: 9-W 13c- Expiration: I l l i b/yL Stove Information Type of Fuel (check all that apply): Wood Pellet Coal Location: -vvr:s q‘.,t Freestanding Insert Manufacturer: (-kt.tiOvv_ Model: CAu)d-ems A-.- -- -----------FOR BUILDING DEPARTMENT USE ONLY Permit# ''°'2')-13110 O Date Applied: Total all Fees: $ /10 C k,CI Lich'1)) Building Official: 41)))..) /25.5 Date Issued: /a- ZS-ZOZ 2 (Print) ///� Signature of Building Official: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center • 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): McKenney Electrical- Co. Inc. Address: 100 Northampton Street City/State/Zip: Holyoke, MA 01040 Phone#: (413) 536-5551 Are you an employer? Check the appropriate box: I I Type of project(required): 1.❑X I am a employer with 4 4. ❑ I am a general contractor and 1 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' 9. El Building addition [No workers' comp. insurance comp. insurance. 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 employees. [No workers' 13.® Other Solid Fuel comp. insurance required.] appliance install *Any applicant that checks box#I 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 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: Liberty Mutual Insurance Policy#or Self-ins. Lic.#: XWO(2 2)5 7 8 7 2 25 9 Expiration Date: 0 7/20 23 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 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: . Date: Phone#: (413) 536-5551 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): I❑Board of Health 2❑Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 5Ek'lumbing Inspector 6.0Other Contact Person: Phone#: „7-4 ea#2~,bepeezil o/A Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration -___� Type: Corporation 1' r r Registration: 200135 Wit".° R4EY EL ECTIR/CENL CO.INC. ` M r» Expiration: 11J16/2022 Tao NORIFIHAIMPTION S1fREET i � _ 'tti IH OLY O E,'MA I011'0 ! , n{ .r . "`� \,,\•`,•�,� �Phi”�. � .. Update Address and Return Card. SCA 1 0 20MM-05//117 y /, U viwiepni. Ianol/�.:%rl?.eY1(I.MIA1P�.ei ,,7Mrmr. C1naarannverit8feirs Sarraiarea±='firoaikdBian MAW:IMPRINTEMENT CCAVITR A,-1 r.aX Registration valid for individual use only rr E:<.'soro raLo before the expiration date. if found return to: FttliaBIBBME ii rate? Office of Consumer Affairs and Business Regulation terott5 /viz= 1000 Washington Street -Suite 710 IIVO EKINIEK'SUP.C;Ut•R!:!L.C'D.7tr;. Boston, 0211S INGRAIM1111E VW Iwo luI z>s* 2Et KITQh2YWE,f4YA Ot040 Not valid without signature I'ti rder.9s�ra m.," Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructipn-S. tV 6—or Specialty s ires:08/0212024 CSSL-106199 4. Nt3ASA(E WI AM,, :a S R SSIB L.V1J-E I MH' SCSIITMAOSPliDite Commissioner :Yij:i>�i Workers Compensation And Lrnpluyen, l:isurauwi Policy WC 00 00 01 A Coverage is Provided In: Policy Number: liberty Tie Ohio Casualty Insurance Company XWO (23) 57 87 22 59 P. Mutual. Prior Policy Number: INSURANCE XWO(22)57 87 22 59 NCCI Co.No. 11363 Workers Compensation and Employers Liability Insurance Policy Information Page ITEM 1:The Insured &Mailing Address Agent Mailing Address&Phone No. - MC'KF.NNFY F,LFCTRICAL COMPANY INC (413) 536-0804 100 Northampton St MARTIN J. CLAYTON INSURANCE - Holyoke_ MA 01040 AGENCY, INC 1 649 NORTHAMPTON ST IONI HOT.YOKE, MA 01040-1933 _Individual _Partnership X Corporation or FEIN: (1,42259517 NAICS:451 Other workplaces not shown above: ITEM 2 The policy period is from (17.01/2022 to 07/01/2023 12:01 am Standard'I imeat the insured'•mailingaddress. ITEM 3 A.Workers Compensation insurance: Part One of the policy applies to the 'Workers Compensation Law of the states listed here: MA B.Employers Liability Insurance: Hart Iwo of the policy applies to work in each state listed in Item 3,A. The lirnts of our liability under Part Two a-e: Bodily Injury by Accident 5500,000 each accident Bodily Injury by Discasa 5500,4D0 policy limit Bodily Injury by Disease S500,000 each employee C.Other States Insurance: Part Three of the policy applies to the states. if ary, listed here: See Extension of Informat on Pogo D.This policy includes 1flese endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 4 The peornium for th's policy will be determined by our Manuals of Rules, Classifications: Rates and Rating Plans, All information required below is subject to verification and change by audit. Classifications Code Premium Basis -Total Rate per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium Soo Extension of Information Pagc{s) Total Estimated Annual Premium Total Surcharges and Assessments Minimum Premium MA Total Estimated Cost I` indicated below. interim adjustments of premiums shall ho made. Deposit Premium Countersigned by: Issue Date 05i0222 To report a claim, call your Agent or I-844-325-2467 WC0100001 A ( 4'C 311 10 E) © I987 Nations] Council on Compensation Insurance, 1nc. 0E:02122 570722ES POLSVCS 450 PGXFPPNO INSURED GCrY 004114 PAGE. 15 OF 41