37-008 (9) BP-2023-0269
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-2023-0269 PERMISSION IS HEREBY GRANT D TO:
Project# MP-2004-0127 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 Phone: Insurance:
100 NORTHAMPTON ST (413)586-5351 XWO2257872259
HOLYOKE, MA 01040
ISSUED ON: 03/07/2023
TO PERFORM THE FOLLOWING WORK:
WOODSTOVE 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:
'1I. 2 .
ror
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
g,zt,k ; v b4 (. mc6&7 E/ Lear- c , ( 1)721,
City of Northampton
OLti
Massachusetts Age �rf
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tl�E Y(c p c� m
' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
�.`.-w Northampton, MA 01060 sy�-
Ctufat, 777 4 yo
APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION -T
Property Information
Owners Name: Lam- e.
Address: 4f-0 Flaccnre `Roo-sN, Florence 141v9 OPtGa
(No.) (Street Address)
Phone: 6/1_ g 3 Cell: Email:
Owners Signature: Date:
Contractor's Information (If Applicable)
Name:NocU w,ne /r'1cKenney Alec-rir. Phone: 3-S3N-,5`Ssl
Construction Supervisor's License #:(5St,- /04 ►c}q Expiration: 1r- -aoay
Home Impr. Contractor License #: 200/ Expiration: 2-c-. o r
Stove Information
Type of Fuel (check all that apply): Wood V Pellet Coal
Location: 15 f Flea r Freestanding Inset t ✓
Manufacturer: tiew-I1,\,s10,,,e. Model: C I y A,es
-- ------------FOR BUILDING DEPARTMENT USE
Permit# "o?I "J Date Applied: Total all Fees: $ -~
Building Official: I Lu tis5-3 Date Issued: 3-7- ZOZ3
(Print)
Signature of Building Official: / //�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ir
Office of Investigations
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): 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.OX I am a employer with 4 4. DI 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. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
A 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.
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: 77o cIc Bence (d :::ity/State/Zip: Re,rr.-e,, w,yq 0w6. .,
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 cer under a pacts and penalties of perjury that the information provided above is true and correct.
7
Signature: . �, Date: �?.i ; )
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 50Plumbing
Inspector 6.0Other
Contact Person: Phone#:
Workers cumptauadun And l;uipluyia Liubilily Iubunutee 2ulivy' WC no 00 01 A
Coverage Is Provldod in: Po1ay Number
II'' Li bcat catty Tire Ohio Cesuelty Insurance Dormant XWe tU ar 8T Zz Se
Mutual. Mr] j` 7N87
rrrsuRANce
NCCI Co.No. 1113631
Workers Compensation and
Employers Liability insurance Policy
Information Page
ITEM 1:The Insured&Mailing Address ,ant Maiiln Address&Phone Ko-
MC°KFNNFY ELECTRICAL COMPANY INC (413) 536-0804
100 Northampton St MARTIN J. CLAYTON 'INStURANC.E
Hnlynkc, MA 01040 AOENC'• INC
,'.:s:. I fi49 NORTHAMPTON ST
HOT.YOiCF., MA 01040-1 9 33
ra eat
_Individual Partnershipcalamm
IN:042259517 11ACSs+51 l 4(l
X Corporetlon or I�_.
Other workplaces net shown above:
ITEM 2 The policy period is from 07r0112022 to 07101 2023 12;01 am Standard'I imeat the insnrcd' ilingaddress.
ITEM 3 A.Workers Compensation Insurance: Part One o'the policy applies to the Workers Compensation Law
of the states listed here: MA
B.Employers Liability Insurance: Part Iwo of the policy applies to work in each slate listed in Item 3.A.
The limits of our liablity under Part Two are: Bodily Injury by Accident $500.000 each accident
Baby Injury by Disease $500.000 Policy limit -
Bodily Injury by Disease $500,000 each empl•'
C.Other States insurance: Part Three of the policy applies to the states. if ary, listed here: See
Extension of Infortnat;on• Pogo
D.This policy Includes these endorsements and schedules: see Policy Forrrs and Endorsements Sur irnary
ITEM 4 The premium for this 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 Rata per Estimated
No. Estimated Annul $1110 of Annual
Remuneration Remuneration Premium
Soo Extonsion of Infornation Pogo(s)
Toth Esiimeted tinnual Prrarrium •
Total Surcharges and Assessments
Minimum Premium MA Total Estimated Cost
I`indicated below; interim Attjustmants of premiums shall be made.
Deposit Premium
Countersigned by:
Issts Dale t O222
To sport s chtha, salt your Agent or f-8414-325-2487
we 00 00 01 A (WC 30 1 Y E)
a I owl Natiwmal Council on Compensation lfMlrautcc.
V Commonwealth of Massachusetts ~
Division of Professional Licensure
Board of Building Regulations and Standards 1
Constructi 'S\cttripervisor Specialty
.. , I .
CSSL-106199 .401111, , Expires:08/02/2024 I
•
8 RUSSELLVILLE RD —
SOUTHAMPTON MA 01073 .%
I
Commissioner .d K. t7 m;rlt2
•
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Aff. ,Q •`Business Regulation
1000 Washing ,:. -Suite 710
Bosto -- •.---=118
Home •Im•ro �_v•• -•- -.istration
,1rn Li -/
Z
^ • V:: Type: Corporation
MCKENNEY ELECTRICAL CO,INC _ •egi5t ation: 200135
1 6:lion: 02/05/2025
0/5/A MCKENNEY HEARTH&HOME :. ■
100 NORTHAMPTON STREET , Q'/
HOLYOKE,MA 01040
•,o =_ I'-
I♦ Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Co7pofation Office of Consumer Affairs and Business Regulation
Reaistratiott ?:='Fxoiration 1000 Washington Street-Suite 710
2QuI35. Ui;02105/2025 Boston,MA 02118
MCKENNEY ELECTSICAL CO;lNC,
O/6/A MCKENNEY HEARTH&HOME -
� .i{
NORA WINE r i' � l.'
‘--- ( Olt— L-------
100 NORTHSi*AMPTON S7 ,,,,,,+ya.r
HOLYOKE,MA 01040
Undersecretary Not valid without signature