35-124 (4) BP-p23-0 168
13 DREWSEN DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-124-001 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-2023-0168 PERMISSION IS HEREBY GRANTED TO:
Project# WOOD STOVE 2023 Contractor: License:
Est. Cost: 4915 SAL-CZAR INC 103963
Const.Class: Exp.Date: 05/18/2023
Use Group: Owner: M GOODMAN RACHEL
Lot Size (sq.ft.)
Zoning: WSP Applicant: SAL-CZAR INC
Applicant Address Phone: Insurance:
53 NORTH ELM ST 413-536-7171 WCC 5005098312022
WESTFIELD, MA 01085
ISSUED ON: 02/10/2023
TO PERFORM THE FOLLOWING WORK:
INSTALL 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:
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: I 59J5/F
Jam+ -
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240.Fax: (413)587-1272
Office of the Building Commissioner
........„ / ,,
nul.- 24-iycv-- /‘i e-e. ,
Se, 7Jc
. The Commonwealth of Massachusetts
IV)
�l' ''"' -� FOR
Board of Building Regulations and Standards,Massachusetts State BuildingCode, 780 CMR �` `;VIIdNICIPALITY
�,r, a
Building Permit Application To Construct,Repair, Renovate Or, e Jsh a kevisedMgr 2O11
One-or Two-Family Dwelling i a 'ri J,
,,/J�/� This/_Section For Official Use Only % - �Oy /
'✓, ' i7.- //p 1 n;' fir-"^.,
Building Permit Number: Y Date Applied: � ; r�i
teevrk, 7Z-55 / �1'or:
110 cr7o__,j Z-10-ZOZ
Ns
Building Official(Print Name) Signature � Date 3
SECTION 1: SITE INFORMATION
1.1 Property Address: 0 v,QGc1414-.. - 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
I z tei►nc. S/Qc3L Porencr. , MA I Oib(002
Name(Print) City,State,ZIP
I S `*[Ct-J —I:v,u,c
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other At Specify: (,v 00a S6„.L
Brief Description of Proposed Work2: E ny}A II wa, S.lovt p n c Pa A L r 4-4-. 6 t"
woc•\ s-Vov� -;P e
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determi-ted:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire f
Suppression) $ Total All Few 4 7',(
r, bS Check No. heck Amount: -`V Cash Amount:
6.Total Project Cost: $ 1.1 1 vl 1 S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS_ Inc)(03 S- 1$-�3
�("A�j Q(�U License Number Expiration Date
Name of CSL alder
l t,p r I Gr`C n CL List CSL Type(see below)
No.and Street Type Description
, 1 �l U Unrestricted(Buildings up to 35,000 cu.ft.)
i'Y1GeY1 'O' r MA I `�a R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
41 3-4 S�I SF Solid Fuel Burning Appliances
3 I Insulation
Telephone Email address D Demolition
5.2 Registered/� Home Improvement Contractor(HIC) Sg 1-1-23
SAL— CZ<"7 2 IN Q. HIC Registration Number Expiration Date
HIC Company Nagle or HIC Registrant Name
S3 JU. sA-
o)an�-rV ,� A Email address
W �'m a 01 oas y13-s3to-717i
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes No . ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize _
to act on my behalf,in all matters relative to work authorized by this building permit application.
1Q ur►n� 'a I -10 - 2o23
Print Owner's Name(Electronic Siature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
SA-ac Lolvec�v I - IQ, - 2e3
Print Owner'ar Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
4 Massachusetts
-- DEPARTMENT OF BUILDING INSPECTIONS A'
212 Main Street • Municipal Building
Northampton, MA 01060 ''Pk 2 ��
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date:
•
.16.—
The Commonwealth of Massachusetts
,IWiiim(6i Department of Industrial Accidents
I Congress Street,Suite 100
--
111
Boston,MA 02114-2017
..... .
www.mass.govidia
— li'utters Cortipetssation Insurance Affidavit:Banders/Contractors/ElectriciansiPlunsbers.
TO RE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leksiblv
Name(RusittessiOtgantrationflndwiduall: SQL -C.2 E (2., —s... C.
Address: 53., N._
City/State/Zip: W-e4.e. t
A.AA 00%c,— Phone#: Lli - Slal- 309 3
Are yss an employee?Cheek the appropriate boa: Type of project(reqaired):
I.71..i am a employer with___(1 _employer-a tfull arutihst part-tinael-• 7. 0 New construction
2 0 I am a sole pinpricks or partnenthip and have no employers working for irr*in 8.. cj Remodeling
arty orpecity.(No workers'comp.insurance respired'
9,10 I am a homeowner doing all uork myself fNo MALitirs'comp.inwaranne required"0 0 Dentolition
1 0 0 Building addition
4 El I am a homeowner and will be hiring ooturaaort to nandua all work on my property_ I will
tilsialt that all contrseturs either have workers"iiompernalion insurimis or are sole 11 ci Electrical repairs or additions
proprietors with no einpluyem.
12.0 Plumbing repairs or additions
SCII am a sellers]tontractior and I have hired the sub-eontraetors listed on the attached sheet.
I 31:3 Roof repairs
Thew sub-cunirackira hate employees and have workers'vamp.insurame.:
14.CaOther LA)CoA <)-)-c)skt?
h.r:j Vie MK a colixwahuti and AA offittent have exervitted their right of exemption per bil:il c.
152,t it4),and we have no unployees.[No workers'worm.insurance tenth:LAI
in)applicant that isluxio,boa#1 mina Alan fill nut the seciotni below,Atom.tug their 16 uric's,'convent/mon polk-y information_
3 Itomeownem who subunit this atitclattli irulkatimi they are defog all K u rt and then hire 011iMLIC.,unbracturs aunt aubmtt a new aft-ids*it naltc;atzlig i.Ach.
L utlIniCtura that cheek chid boa must attached an additional sheet show ins the name of the,wth-contractora and,tioa Ve!walla or noi thou titititt haw
employee., lithe sub-contractor%haw employ LVS.they must pnyelde their workers'cotrip pktlic.: ratrinher.
I ant an employer that is providing workers'compensation insstronce for my employees. Below is the policy anti job site
information.
insurance Company Nanie: 4i M _
Policy#or Self-ins.Lic.#:L1/4)QQ_ 500 Spoci 16-3 I)402 A Expiration Date: 3);401 202,....
Job Site Address: G —1D c t us.) --t.CiVe,__ City/State/Zip: Hort")cji..1 MA 010C;(2
Attach a copy of the workers'compensation pinky declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MCiL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penaities in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby certify nder the twins and f nalties of"Wary that the information provided above is true and correct.
Sipa ture: A,Ji a.t ,i ti-611 a Date: I - i?)--• ,2-0 -.-2-
phone f..4-113-- Sts 3C)C1.21
(
Wald use only. Do not write in this area,to be completed by city or town offkkd
City or Tows: Permit/License# ,
Issuing Authority(drde one): :
I. Board of Health 2.Bantling Department 3.CIty/Town Clerk 4.Eleetrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ Phone#:
n
i"1 CZARENE-01 JCHOINIERE
A4C-0/20 DATE(MM/DDIVVW)
4....----- CERTIFICATE OF LIABILITY INSURANCE _ 3/17/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.- _________ _--1
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _.___.__ --- H
CONTACT
DROOUCER
NAME: - ---
McClure Insurance Agency, Inc. PHONE (413) 781-8711 FAA,NoL(413) 731 8548
1)3 Van eene Ave. E-MAIL
Vest Springfield, MA 01089 ADDRESS:
_ INSURER(S)AFFORDING COVERAGE NAIC e
.. _ _ INSURER A:Berkley Specialty Insurance Company. 1_31295._-._._., ._
NSURED INSURER B:Safety Insurance Co._.____
_ 39454-.___-.
Sal-Czar Inc.DBA Czar Energy Solutions INSURER c:Associated Employers Insurance_Compaq 11 _104 _._ .
8 Victoria Lavertu '
INSURER D: _ -. _---.
53 North Elm Street - -
Westfield,MA 01085 INSURER E: _--- .
INSURER F: ------- r
:OVERAGES CERTIFICATE NUMBER: REVISION NUMBER. --
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FDR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ---------
uSR ADDL SUER POLICY EFF POLICY EXP LIMITS ____ _ _
TYPE OF INSURANCE POLICY NUMBER /MM/DCWYYY) IMM/DD/YYYY1 l -
TR ws0 wv0 "— - 1,000,000
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ __. .$ -.._. -_.
-- DAMAGE TO RENTED 300,000
JCLAIMS-MADE L X J OCCUR BPK 0123592-22 3/10/2022 3/10/2023 PREMISES LFs.uccurr0nu;). $ 5,000.
MED EXP(Any onepe rson)_,._. $ _ _ ._.-_ -
—_ __— 1,000,000
PERSONAL 8 ADV INJURY _S .. - -
-� --____ 2,000,000
GENERAL AGGREGATE;. _ .1 .--- - -- - .
GEN'L AGGREGATE LIMIT APPLIES PER. 2,000,000
I I PRO• p ooucTS__COMp/OP rGG ,_$........__..__--------- ---
X POLICY Li JECT L.__I LOC L
OTHER COMBINED SINGLE LIMI I 1,000,000
B i_AUTOMOBILE LIABILITY (Ea accident) -._
6209399 3/10/2022 3/10/2023 BODILY INJURY Perge.l.un). $ __ --
ANY AUTO _
I` `/ BODILY INJURY(Per aCr.'JenIZ_$ -- - -.-
i OWNED X SCHEDULED ---'
AUTOS ONLY AUTOS PROPERTY DAMAGE
NON-OWNED X HIRED �(
(Per acuden� _--
_ _ S ._._._...--._..... _
AUTOS ONLY AUTOS ONLY 't ---
_- _EACH EACH OCCURRENCE I$ _. -__-.. _
UMBRELLA LIAB OCCUR
,- _AGGREGATE ..j __ ---
-
I I EXCESS LIAB CLAIMS-MADE r IL
j DED RETENTION$ T OIH- I -
—___ X l PGTATLI.IS.-_l.__ r�l' -
C WORKERS COMPENSATION I 100,000
AND EMPLOYERS'LIABILITY YIN 3/26/2022 3/26/2023 �—---
YIN EL EACHACCIDENI 100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE I N I NIA - - -
OFFICER/MEMBER EXCLUDED' L J E.L DISEASE EA EMPL )YLE $�.. SOO,000
(Mandatory in NH) .POLICY OMIT F _-----y
II yes tlesrrrbe under E L DISEASE _ '
_ DESCRIPTION OF OPERATIONS below
I
I
)ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required)
J
CERTIFICATE HOLDER _ -___ CANCELLATION --—" -
SHOULD ANY OF THE ABOVE DESCRIBEDNOTICES BE WILL CBEC DELIVERED RIN
E
THE EXPIRATION DATE THEREOF,
ACCORDANCE WITH THE POLICY PROVISIONS.
To Whom It May Concern
AUTHORIZED REPRESENTATIVE
i _--- ---- 1988 2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03)
The ACORD name and logo are registered marks of ACORD
/17
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
Registration: 163596
SAL-CZAR INC . Expiration: 07/07/2023
D/B/A CZAR ENERGY SOLUTIONS
53 N. ELM ST
WESTFIELD,MA 01085
Update Address and Return Card.
SCA 1 ii 20M-05/c1177
77D. ffi(4-of/Plon.st rrer ai478 d‘siness'4 egu1MGon
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
163596 07/07/2023 1000 Washington Street -Suite 710
SAL-CZAR INC. Boston,MA 02118
D/B/A CZAR ENERGY SOLUTIONS
STACY LAVERTU /
53 N ELM ST , �%�"�z
WESTFIELD,MA 01085 Not valid without signature
Undersecretary
Comm Massachusetts
Division of Professionalonwealthof Licensure
Board of Building Regulations and Standards
Construct bttJpervisor
CS-103963 • 50,cpires: 05/18/2023
STACY A LAVERTU
106 FLORENCE RD 3s
EASTHAMPTON MA 010.27 -
\` rrG4
d
'
Cornmissioner % l