25A-128 02/21/2013 17:18 FAX 14135388753 OLDE HADLEIGH HEARTH PAT 11003
I12/ 21/2E113 13:14 4135328522 METRAS INS PAGE 02/05
1 AC±C�RD_,. CERTIFICATE OF LIABILITY INSURANCE BATA z 20 3
1 PROOUOER (413) 536 -1491 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Metros Insurance Agency, AND CONFERS NO RIGHTS UPON THE CERTIFICATE
At ncy r Imo , HOLDER, TWIN CERTIFICATE DOES NOT AMEND] EXTEND PR
20 Memorial Drive ALTER TM
- E CCaV, RAGE AFFCIVED BY THE POLICIES BELOW.
1
h.ic ocrpee — ) 'IA. 03,020-• INSURERS (IFFO lDING COVERAGE NAIC # ^ _, y
INSURED
1 O246 Fladleigh HAarth & Home Center, Inc. INSURER B; -
119 1111inamaett St. INSURER C_ — `yam
INMURC O:
South Hall r 01075- ■ INSURER V!
. _ _
COVERAGES _
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A BOVE FE/Ft THE POLICY PERIOD INDICATED. NOTIMTH$TANDING ANY
RE0UIREMI:NT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY se ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
GGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C u,.
'NOR ADD POLICY EFFECTIVE POl I LIMIT
LTR I -:-,. TYPE OFINSURANCQ - POLICYNumBER • It MMeDD D --
A GENERAL wean 16607910,p71e OB/30/2012 Or8/30/2013 EAcm_°ceuRRENcE B 1,000,000
•MMERCIAL QGN9LV1B1417Y oerulrorloily S 100,000
IIIME CLAIMS MADE I I GGDUR / / / / MBD GYP (Any and Per j 3 $ 000
• PERSONAL36VINJURY 3 1,000,000
ill / / 1 / GENSRAL AGGREGATE 3 2 , 000, 000
OEM AGGR80ATEUMrt APPLIES PER; PROMOTE CONtPI0P?AG 3 2,000,000
In POIC I. II ..." El Ito / / M / / .
A AUT0someU63p,11Y $A2055C668 11/01/2012 11,/01/2013 Gomm BINGI,E4IMIT
al ANY AUTO Ma aaddenO s 1,000,000
• ALL OWNED AUTOS / / / / BOolLY INJURY
S I-J3 ULL�b AUTOS (Par pw cn) $
HIRED AUTOS / / / I DO DILY PIJURY
ill NON.OWNEo Au-r03 (Far rocket e) !
/ / / / PROPERTY
(PMAOOIEanI) 4
« „..,..y
GARAGE LIABILITY AUTO ONLY • EA ACC1D IP
ANY AUTO / / / / o THAN EA A00 S
- AUTO ONLY; A00 $
A ExcES31UM®REL1.A L1ABRun' 254 9r614 08/30/2012 Di/SO/2013 EACH OCCURRENCE $ 1,000,000
fl QCCUR E CLAIMS MACK AGQR®OATTI S 1,000,000
3
III DEoUOTMLR / / / / - 3
= gylYnON $ 10.000 .» /1,21 � 3
A WORKERS GOMPENBATIGN IBUB5197BA1 0'x/12/2012 O'P2013 Y P""� ° I '
EMPLOYERS' LIABILITY -
ANY PROPRIETOR1PARTNER c„TIVE AL, BAGN %CCOENT ± 100, 000
DFFICERMAEMPAR 6XCLUOE07 / / / / .E,L DISEASE. BA NAPLoYEE $ 100 , 000
It ye. dour be under
...Facial, PRoviet9pg wow _ E.L. DISEASE . POLICYLIMIT A 500,000
OTHCR / / / /
/ / / /
/ / / /
DESCRIPTION OF OPERATIONWLOCATIONSIUEMCLRWGXCLUslONS ADDED BY !NPORS3MENT19PEC1AL PROVISIONS
CERTIFICATTA HOLDER _ CANCELLATION
( ) - ( ) - SHOULD ANY 4P THE ABOVE 0!SCRISID Mums BE cANCRLLED BEFORE THE
BXMRATIDN DATE THEREOF, rH *CUING INSURE! WIU. ENDEAVOR TO MAN_
DAYS WRITTEN NO110E TO MG O RTIRCATE HoLO!R NAMGD TO THE LOT, rut
Barry Ngrosh FA3-URE TO DO 30 SMALL IMPOSE No o3u¢ATI011 OR LIABILITY OF ANY IMO mom THE
21 Mates Strout ImaURm% ITS AOENe$ OR REPRE8ENTATIV 3.
Am aRA:=D REPREIIIPNTATIVE grace/ J 4fll ,] pi /A i j �
Worttrampton MA 01060-- _ . (✓ 4F
ACORD 25 (200110B) B ACORD CORPORATION •988
INSOZS (01De),os Popo 1 oft
A ;
02/21/2013 17:19 FAX 14135388753 OLDE HADLEIGH HEARTH PAT WI006
Ntttr - Ocll,trtrrtent of Public S;it'et '
Board of Building Regol;lt•iitn. and Standard
Construction Supervisor Specialty License
License: CS SL 98784
Restricted to: SF
MATTHEW COX
54 HADLEY STREET
SOUTH HADLEY, MA 01 075
Expiration: 4)28/2013
('urithik inner T # 12985
g r ith o
• .
OffiCe of Consumer Affairs and Business Regulation
bIt 10 Paxk Plaza - Suite 5170
Boston, Massachusetts 02116
• .Home Improvement Contractor Registration
Reglstreti0n: 148196
Type: Private Corporation
Expiration: 9/13/2013 Tr* 216476
OLDE HADLEIGH HEARTH & HOIVIE`CE T
ALAN GOUNSKI - ._.,......
119 WILLIMANSETT STRETT RT 33
S. HADLEY, MA 01075 --- — - - _........,.._.......
Update Address and return card. Mark reason for change.
Address ❑ Renewal C Employment Lost Cord
lg eoononovrsr 44 0)1 aCk
Office or Consumer Affairs & Business ReguIntion License or registration valid for individul use only
jip ROME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Regiatratlon: 146198 Type; Office of Consumer Affairs and Business Regulation
4"P = Expiration: 9/13/2013 Private Corporation 10 Park Plaza - Suite 5174
Boston, MA 02116
I ..OE HADLEIGH HEARTH & HOME CENTER, INC.
AN GOLINSKI
9 WILLIMANSETT STi:E`TTRI' 3
-
HADLEY, MA 01075
' Undersecretary Not valid without signature
..
i•
02/21/2013 17:19 FAX 14135388753 OLDE HADLEIGH HEARTH PAT al 005
The Commonwealth of Z1assachusetts ::,'',v`:;:1". :)M' 6';
Department of industrial Accidents
,, , ,,'d', Office of Investigations
I� 1 Cortgrie is Street, Brune 100 •
w4° Boston, MA 02114 -2017 1
,.t` 7� 1 www.mass.govidia
Workers' Compensation Insurance Affidavit: Builders /ContraalctorSFEiectricians /Plumbers
Applicant Infarmai Pia nt. bW
Narne (Business/Organizatlon /Individual): tilde Hadleigh Hearth& Home Cerltef', Inc.
Address:
119 WIlif Street
•
City /State /Zip: _South Hadley, MA 01075 phone #:413/538 -9845
Are you an employer? Check the appropriate box: Type of project (required):
1. [✓ I am a employer with 8 4. ❑ I am a general contractor and I
employees (full and/or part - time).* have hired the sub - contractors 6. ❑ New construction
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have+ no employees These sub - contractors have S..0 Demolition
working for me in capacity. employees and have workers'
g any tY . # 9. 0 Building addition
No workers' 'comp. insurance comp. ir13111arlce.t •
required.] 5. 0 We are a corporation and its ` 10.0 Electrical repairs or additions
3. ❑ l am a homeowner doing all work officers have exercised their ! 11.0 Plumbing-repairs or additions
myself. [No workers' comp. right of exemption per MOL 12.0 hoof repairs
insurance required.] u t C. 152, §1(4), and we have no..
9 ] 13.0 other • Install wood stove
employees. [No workers' �--
. _ - . comp. insurance required.] -
" Any applicant that checks box 111 mast also fill out the section below showing their workers' compensation. inibrmetion.
t Homeowners who submit this affidavit indicating they ate doing all work and thenitire outside contractors mist submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name Odle sub•cootmetors and State whether or not those entities have
employees. If the sub- coitractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for .m employee4 Below is the policy and Job site
information.
Insurance Company Name :Travelers Insurance Home Improvement Contractor's Liskense #148198
Policy # or Self -ins. Lie. #:I5UB5197B81 Expiration D ate: 7/12/2013 ��//
Job Site Address: 0 ea 4-5 -"7`. City /State/Zip: /4k7 4rxr� 4 /', no Q /4
Attach a copy of the workers' compensation policy declaration page (showing the plpliey number and .expiration date).
Failure xo secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500:001 and/or one -year imprisonment as well as civil penalties in the forni of a STOP 'WORK. ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement mays be forwarded to the Office of
Investigations of the!DIA for insurance coverage verification.
1 do hereb certify under the ains and renaltiekof perfulthai the tromration provided above lis true mamma
Si ature: 8/10/2012
1
Phone # : 538 -9845 CS SL 087 • ,
Official use only.) Do not write** this area, to be conyileted by cltyor town ollcalnLl
City or Town: Permit/License # _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ipector 5: Plumbing Inspector
6. Other -
Contact Person: 1 _- -- Phone #: i
Amaniner
X1002
HEARTH
02/21/2013 17:18_ FAX 1413 OLDS HADLEI NIGRTSH
5388± 53 PAGE a2 /a2
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tE "�v , Fat 2 ��r. QB' �iLDSIPG .IrT�$"L'TY(+�IPb` l� / 212 r • �tiltrtlaf B14744 '
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M- •t WA 01.060 �
DEPT. OF B i L U C. IIV:FECTIONS
NORTHAMPTON, MA 01060 •
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 • Check # Ulf 6 t,'
PLEAS PE OR PRINT ALL INFORMATVON
1. Name Of AppUGant: Z 1 %R.__ �. y 4 "
Address: d-- l tC Cr _041 J *prime: L � "•
2. Owner of Property: A �2 IA 1 ►Gr + 1 C G ► . a '
Address•_. 0 t & ` ,s'r r T9lephorra: A- 17+F
3. Status of Applicant:, Owner Contractor .
4. Type ar Brand of 5hwac_ Tar v L O' 16 1y 4 i c7 Q C
If applicant is not the homeowner ��� �� Y,/#11/1-3
Construction Supervisor's License Number ,r Expiration Date
Home Improvement Contractor Registration Number / 067 ' 91 Explretion hate 1 ,f, 3�/ -
All Applicants must coevals a Workers Compensation Insurance Affidavit before we Gran issue a permit
5. Cer fiicatlon: I hereby certify that the inftumatlon centai : • - " is true • ccurate to the best
of my knawletlg . , j /
�T t v APPLICANT'S SIGNATUR ■ tA1141/11111&
DATE; HOMEOWNER'S SIGNATURE
APPROVED
DATE: _ BUILDING OFFICIAL `.
21 BATES ST BP- 2013 -0778
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 128 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2013 -0778
Project # JS- 2013- 001332
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): 19209.96 Owner: NIGROSH BARRY J & ELLEN EMERSO NIGROSH
Zoning: URB(100)/ Applicant: NIGROSH BARRY J & ELLEN EMERSO NIGROSH
AT: 21 BATES ST
Applicant Address: Phone: Insurance:
21 BATES ST WC
NORTHAMPTONMA01060 ISSUED ON:2/22/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL JOTUL OSLO F500 CF
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/22/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner