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46-050 (8) BP-2023-0259 99ISLAND RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 46-050-001 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-2023-0259 PERMISSION IS HEREBY GRANTRD TO: Project# PELLET STOVE 2023 Contractor: License: Est. Cost: NORA WINE CSSL-106199 Const.Class: Exp.Date: 08/24/2024 Use Group: Owner: ADAM BASS, KATHRYN & Lot Size (sq.ft.) MCKENNEY HEARTH&HOME/MCKENNEY Zoning: SC Applicant: ELECTRICAL CO INC Apalicant Address Phone: Insurance: 100 NORTHAMPTON ST (413)586-5351 XWO2257872259 HOLYOKE, MA 01040 ISSUED ON: 03/02/2023 TO PERFORM THE FOLLOWING WORK: PELLET 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I „ SQ Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner City of Northampton Massachusetts4'3 y ' DEPARTMENT OF BUILDING INSPECTIONS �: t �›: ; ,ram '=a 212 Main Street • Municipal Building Q`- er'. Northampton, MA 01060 APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: a.A rn SS Address: q et (slc«,IL (No.) (Street Address) Phone: .btu-.W f b V Cell: Email: • Owners Signatur : Date: Contractor's Information (If Applicable) Name: 10v4& �lv�-c. 'M�l�e�r-v-'-��c E ("--1l11').4 Phone: 1{13.` 1._S 5S1 Construction Supervisor's License #: C SSL-((7101 etc.1 Expiration: F4)-10-7 Home Impr. Contractor License #: )3 5 Expiration: a/512-5- Stove Information Type of Fuel (check all that apply): Wood Pellet ✓ Coal Location: fitik l-- 1 Freestanding Insert Manufacturer: e - A 4 Model: j2 V- BUILDING DEPARTMENT USE ONLY-----------___________— Permit# €JP 673- ate Applied: • Total all Fees: $ '' Cam''LL.7 /S' Building Official: / cures ' 20.5s Date Issued: '3. 2-23 (P ° Signature of Building Official: ,///Gr The Commonwealth of Massachusetts Department of Industrial Accidents =� —I Office of Investigations Lafayette City Center w 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: Type of project(required): 1 1.© I am a employer with 4 4. [] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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. 0 Demolition workingfor me in anycapacity. employees and have workers' P h• 9. 0 Building addition [No workers' comp.insurance comp.insurance.: required.] 5. 0 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 12.0 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. 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 7 225 9 Expiration Date: 0 7/2 0 2 3 Job Site Address: g LSll 4n.. - get City/State/Zip:N ^A^"i , 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 herebyy�cerrtify under the pains and penalties of perjury that the information provided above is true and correct. 14 Signature: . ' `�( 5' Date: )"_31 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): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5.alumbing Inspector 6.DOther Contact Person: Phone#: Wurkc:rs Con4xnwition And 1,cnpluyc;in Liubillly luwrtuuo Policy" WC 00 oo U1 A ccvwo?o is Proridr.d in: Policy Number: 'Liberty XWO[23l 17 87 22 eel �,,r, Mutual. Tie Ohio Casualty insurers* G�arn � �Nurr,ba afr INSURANCE 1(llt0 tZLI of 87 r: 1 NCCI Co.No. 11136 Workers Compensation and Employers Liability insurance Policy Information Page ITEM 1:The Insured&Mailing Address ant MOM Address 8r Pbone No. MMCKFNNFY ELECTRICAL COMPANY TNC. (413) 536-0804 100 Northampton St MARTIN I. CLAYTON TNS1TRANC!. Holyoke; MA 01040 AOFV'CY. INC 1649 NORTHAMPTON ST HOT.YOfKF.. NIA 01040.1933 : _,Individual Partnership tea;042259517 NAq a5114q X Corporation or Other workplaces not shown above: ITEM 2 The policy period is from 07,01:2022 to 07/01/2023 12:01 am Standard,imcat the insured'srnailin&address. ITEM 3 A.Workers Compensation insurance: Part One or the policy applies to the Workers Compensation Law of the states listed here: MA B.Employers Liability Insurance: Part Iwo of the pulley applies to work in each state listed in Item 3.A. The limits of our(ability under Part Two are: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease S500.000 policy Omit 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 Inforrnat:on. Page D.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,'Classifications! Rates and Rating Plans.AO Information required below is subject to verification and change by audit.. Classifications Code Premium Basis-Total Rate per Estimated lin. Estimated Annual $100 of Annual Remuneration Remuneration Premium Soo Extension of Infornotion Pages} Total Estimated Annual Premium Total Surcharges and Assessments • Minimum Premium MA Total Estimated Cost If indicated below, interim. Allotments of premiums shall be made. Deposit Premium Cotsitersigned by: Issue Date 05/0Z22 To roport a c oat your Agent or 1-84142.' 24E7 weo00o01 A (WC 3$ 10 E) IOR7 Notional Council an COnu1 Ti8tiCM insurance. 110 Commonwealth of Massachusetts ~ Division of Professional Licensure Board of Building Regulations and Standards COrlstruct oeSlipt ( yspr Spac afty , CSSi -106199 expires:08/02/2024 NORA E WINE' 8 RUSSELLViLLE RD '. SOUTHAMPTON MA 01073 -- /441 • .r__ . Cornmissioner Jict, i�. Si ;• ! • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affa�a�y Business Regulation 1000 Washing`[ -Suite 710 Bosto 118 Home Im•ro egistratian m I,-j1. ^ a key Type: Corporation MCKENNEY ELECTRICAL CO,INC 3 !=t e ' tion: 200135 D/B/A MCKENNEY HEARTH&HOME '{• lijtation: 02/05/2025 100 NORTHAMPTON STREET a,l g v HOLYOKE,MA 01040 ~ r Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:-Cofpiiration Office of Consumer Affairs and Business Regulation Registration "��EXQiratior 1000 Washington Street-Suite 710 200135' -i,G p2/O512025 Boston,MA 02118 MCKENNEY ELECTRICAL-CO;,INC.; DlBIA MCKENNEY HEARTH HOME 1 S i NORA WINE `-• s 100 NORTHAMPTON S e• -gam `: ,,�,,,,,&, .L � HOLYOKE,MA 01040 '. ,�- me'4 y Undersecretary Not valid without signature