22D-055 (3) BP-2023-0258
7 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22D-055-001 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-2023-0258 PERMISSION IS HEREBY GRANTED TO:
Project# WOODSTOVE 2023 Contractor: License:
Est. Cost: NORA WINE CSSL-106 99
Const.Class: Exp.Date: 08/24/2024
Use Group: Owner: CAILIN QUALLIOTINE,
Lot Size (sq.ft.)
MCKENNEY HEARTH&HOME/MC I NNEY
Zoning: WP/WSP Applicant: ELECTRICAL CO INC
Applicant Address Phone: Insurance:
100 NORTHAMPTON ST (413)586-5351 XWO2257872259
HOLYOKE, MA 01040
ISSUED ON: 03/02/2023
TO PERFORM THE FOLLOWING WORK:
WOODSTOVE
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
,9 . cg)„,a.
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of Northampton
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(N�.,�y ( , DEPARTMENT OF BUILDING INSPECTIONS
1' 212 Main Street • Municipal Building a`
( -ti W Northampton, MA 01060 s l"1�-•at jt��4
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APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION
Property Information
Owners Name: Cc I,n + Pe+cc Qv c.1 I►n4i h -e
Address: } Flore.ne-e R fl G(,en« v. GIc 4,D,
(No.) (Street Address)
4'3-41?-1o/1
Phone:a04-H41- 3&I Cell: Email:
Owners Signature: Date: - Li-20 : 3
Contractor's Information (If Applicable)
Name:,t.' -0, w,h a Phone: 9,3_ r34-s-s---/
Construction Supervisor's License #: [,ssc.- I o6 ism Expiration: 9-2-2Ga'-I
Home Impr. Contractor License #: boa 13S- Expiration: 2-5-p.a?s—
Stove Information
Type of Fuel (check all that apply): Wood ✓ Pellet Coal
Location: ) .E rI vO r Freestanding ✓ Insert
Manufacturer: gee.-c+h s ton a Model: C ,_ li t •
----_----_---_FOR BUILDING DEPARTMENT USE ONLY------_----...._-_-_-_-_----
Permit# 6/z 075'Date Applied: Total all Fees: $ 0 cK- y z 7Lt
Building Official: J ui &-5-5 Date Issued: S- 2-ZOZ3
Signature of Building Official: Pn.>)Z
iii Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Carstruct or Silpe sor Specialty
CSSL-106199 = i
> tXpires:08/02/2024
NORA E WINE' • 7. iii I •
8 RUSSELLVILLE RD
SOUTHAMPTON MA 01073 - i
i
r)/SS 1.i0'''s
Commissioner di K.
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THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affai( ala Business Regulation
1000 Washingt e, t,,Suite 710
Bosto 118
Home Im.roverxm a istration
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to �_ I,
m Type: Corporation
MCKENNEY ELECTRICAL CO,INC +�� :Pon: 200135
D/B/A MCKENNEY HEARTH&HOME ". _—_ tion: 02105/2025
100 NORTHAMPTON STREET '� ! s Q'
HOLYOKE,MA 01040 ` i.g�_ /k
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f�^Ji,r ‘.y0
_ • Update Address and Return Card.
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THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME i\7PROVEMENT-CQNTRACTOg expiration date. If found return to:
TYPE:t po'ration Office of Consumer Affairs and Business Regulation
Reaistratioo- ;'Exoiration 1000 Washington Street-Suite 710
200135---1,i:02105/2025 Boston,MA 02118
MCKENNEY ELECTRICAL-CQ;dN r
UJBJA MCKENNEY H -'•
1. I.
NORA WINE
s'
-1,1`. L-----
100 NORTHAMPTON S f/�""'G(/L e..4' p l J
HOLYOKE.MA 01040 :; ...%
._J- Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Iv Lafayette City Center
2Avenue 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): MCKenne-y 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 Type of project(required):
1.❑X I am a employer with 4 4. 0 I am a general contractor and I
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
workingfor me in anycapacity. employees and have workers'
P h• 9. ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5- ri We are a corporation and its 10.0 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.D 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#1 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: Liberty Mutual Insurance
Policy#or Self-ins.Lic.#: XWO(22)57 87 2259 Expiration Date: 07/2023
Job Site Address: t,1/43,--cf,-` ... i City/State/Zip: t l.-e—cr`,c . 6( J b;_
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 c rt unde the and penalties of perjury that the information provided above is true and correct.
Signature ki\)` Date: , )-'/..)---?' "3
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):
IDBoard of Health 20 Building Department 3fCity/Town Clerk 4.0 Electrical Inspector 5Elumbing
Inspector 6.DOther
Contact Person: Phone#:
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wurkurs Cuupoimidon And J. upluy*n LiebiliLy luburuu e Pulit y' WC oo oo O1 A
Comm*!t Provldnd In: Po#ay Nurrbar
ifLiberty Tie Ohio Cesuatty lnnumno, Docuranv X1AI0[ml tIT e7 use
Mutual. wo[�1 -
INSURANC®
NCCI co.No. I11363
Workers Compensation and
Employers Liability Insurance Policy
Information Page
ITEM 1:The Insured 8 Mailing Address eat 6lf111lln Address 8c Phone No-
MCKENNFY ELECTRICAL COMPANY INC (413) 536-0804
MEM 100 Wurthampton St MARTIN 1. CLAYTON 1NSITRANCh
Holyoke; MA 01040 Atli:NC'Y. INC
1649 NORTHAMPTON ST
n ..__. HOLYOKE. MA 0I040-1933
EGER
11111.1.1111.
Individual�Partnershlp FEIN:D42259517 IIAICSx451140
imomal X Corporation or
Other workplaces ant shown above:
ITEM 2 The policy period is from 07101:2022 to 07 01/2023 12:01 am Standard"Iirneat the insured'smailingaddress,
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: Fart Iwo of the policy applies to work in each state iist+ed in Item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 each accident
Bodily Injury by Disease S500.000 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 Page
0.This policy Includes these endorsements and schedules: see Policy Forrrs and Endorsements Summary
ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications1 Rates and Rating
Plans.Al information requiredd 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
Sco Extonsion of information Pago(s)
Total Estimated Annual Premium
Total Surcharges and Assessments
Minimum Premium MA Total Estimated Cost
r indicated below, interim adjustments of premiums shall be made.
Deposit Premium
Countersigned by:
issue Date 0510Z22
Tit rrrport a chit, cal yam-Agent or 1-844425-2487
W OO OO 01 A (WC 311 10 E)
e I Qui Natinn:4 Council on Compensation Insurance..