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38A-070 (6) 163 GROVE ST BP-2019-0731 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A-070 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-2019-0731 Project# JS-2019-001204 Est.Cost: $3962.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STACY LAVERTU - SAL-CZAR 103963 Lot Size(sq. ft.): 15507.36 Owner: PEEPLES GABRIEL Zoning: URB(100)/ Applicant: STACY LAVERTU - SAL-CZAR AT: 163 GROVE ST Applicant Address: Phone: Insurance: 53 NORTH ELM ST (413) 536-7171 WC WESTFIELDMA01085 ISSUED ON.-12/20/2018 0.00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOOD INSERT INTO MASONRY FIREPLACE 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 12/20/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Wt'sv t� �vs�2 T o m _ Z� The Commonwealth of Massachusetts o o ern m Board of Building Regulations and Standards FOR n Massachusetts State Building Code,780 CMR MUNICIPALITY oo �, rn CZ) Building Pen-nit Application To Construct, Repair, Renovate Or Demolish a Revised Mai ?iii/ . = One-or vo-Family Dwelling y T v o_ This Section For Official Use Only o 0 w � Q Building Permit Number: 16r— ( —' '�j � � / Date A lied; In u 110 /00155 1Z-ZO-/8 Cl) Building Official(Print Name) Signature bate SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Asse_s�p rs Map&Parcel Numbers 9t� Paj:e, ,tet acp.K, 2"t A- �? 6 -- 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 Pru;idcd 1.6 Water Supply:(M.G,L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone'? Public❑ Private❑ -- Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: . s NnrUNh"p AAN O%O to O _ p arae(Print) City,State,ZIP Ido.and Street Telephone Fimail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ISE Specify: _ Brief Description of Proposed Work': — MCA SCA r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All F6FC Check No. heck Amount: Cash Amount: - 6.Total Project Cost: $ t ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONS"TRUC"TION SERVICES 5.1�Construction Supervisor License(CSL) Name of SL ler Liccnec Numbci C\pn.rtiun f loc List CSL Type(,cc10(o elig below) _ -- ---- _ No.ane tStrect A — -- --- Typc DC'cIt)Hum rr� ���.,.,,,, (.�-- lhtr�',U'tClcdlRtulthn_,ty�-to :i,11U(1iu-It I -- Cityrlown,Siate.L f, NI RC' RoohngCokcill'y ---- _. — _--_--—_.--- __---- _-- - \\'ti \Vlo(hAk Auld.Saline SF Sabel l-uel 13utnut�� \pl,lt.ut«, MI'v --I InuLruon e Email address D Demolm)n _ ___ __ _. _ __- I... 5.2 Registered Home Improvement Contractor(HIC) J(1 epi! c ---------- IIIC Rc�_.sliatinn Numbo I tlnrdur,n Dail: ' Ht(' ompany Name of HIC'Re rsn)utt Name No an Sa c't -- _ f mail aJdrr„ �!ot City/Town, State,ZIP Tcicphonc SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25('(6)) Worket:s Compensation Insurance affidavit must be completed and submitted with Iht.:gtplication I,nlurr to pu,t idC this affidavit will result in the denial of the Issuance of the building permit Signcd Affidavit Attached') Yes ..... .... No...._. .. ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED\VII •:V---~- OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER\IIT 1,as Owner of the subject property,hereby authorize_ to act on my behalf,fit all matters relative to work authorized by this building petnttt appliC:Wun I ant Owner's Name(Electronic Signature) SECTION 7b: OWNER' OR AUTHORIZED AGEN-r DECLARATION By entering my mime below, I hereby attest under the pains and penalties of perjury that all of the ntlurnt.riton contained in this application is true and accurate to the hest til my knuU IcJgc and underst:tnJtn/ r Pr int Owner's or ALN tired Agcm's Name(Clecu'omc St_naturc) —_,----1)_ite NO TES: I. An Ownct-who obtains a building permit Io do his,'hcr 01111 work.ur an owner who lure,:ur unicgt,tcrCd cunm,ictrn (not registered tit the Home Improvement Contractor(HIC)Program),will no/hats acces"to the:ubination program or guaranty fund under M.G.L.c. 142A.Other important information at file I It(' t'tu_ram Can hr Iirtrrul.n t�wt�.m;Iss'uc_ucg Information on the Construction Super\icor Liccnse can be (bund at tttttt.nr.n,_t+t dlt, 2 When substantial work is planned,provide the information below: Total flour arca(sq.ft.)_ (including garage, finished ba<entenraUrC,,dr:Ck,ur porch) (it oss living arca(sq. Il.) liabmablc room count _— _- Numbeioffireptaccs Numberofbecioom• Number of bathrooms ---- Type of heating System Number of deck.;'porchce Type ofcooling vyslem Enclosed ____Open---_T_--.-_`- 1. "Total Project Square Footage"may be Sub titutcd I'or"Toldt Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual):, (5 L C Address:_L13Al �Dra af City/State/Zip: M 10 Phone - Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 4. ❑ I am a general contractor and i employees(full and/or part-time).* have hired the sub-contractors 6 E)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 g_ [] Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp. insurance.; required.] 5. n We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l.n Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.�Other� comp. insurance required.] cS in 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 mployees. If the sub-contractors have employees,they must provide their workers'comp,policy number. am an employer that is providing workers'compensation insurance fur my employees. Below is the policy and job site nformation. nsurance Company Name: t lv l 'olicy#or Self-ins. Lic.#: (��>! �f�� "S20 A Expiration Date: " ob Site Address: R2_2) GcoiQ, S+rkeA- City/State/Zip:J)mmlasa6p,AIA 0�p0 \ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). railure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certify under a pains anldpenalntiJes�jof perjury that the information provided above is true and correct i i ature: / ��!'v�'!� Date: 'hone#: e Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts Department of Public Safety Board of Building Regulations and Standards License:CS-103963 Construction Supervisor ST ACY A LAVERTU 106 FLORENCE RD EASTHAMPTON MA 01027 Expiration'. 0611e120119 'Commissioner QIX? Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Map"qhusetts 02116 Home improveme4g&tractor Registration Type: Corporation Registration: 163596 SAL-CZAR INCExpiration: 07/07/2019 D/B/A CZAR ENERGY SOLUTIONS j 53 N.ELM ST WESTFIELO,MA 01085 Update Address and return card. Mark reason for change. SCAI Co 20M-05011 0 Address 0 Renewal 0 Employment 0 Lost Card Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooration before the expiration date. It found return to: 01ftsimkitlion Expiration office of Consumer Affairs and Business Regulation _6 163696 07107/2019 10 Park Plaza-Suite 5170 I-CZAR INC. Boston,MA 02116 DIBIA CZAR ENERGY SOLUTIONS STACY LAVERTU 53 N ELM ST WESTFIELD,MA 01065 Undersecretary Not valid without signature CZARENE-01 ATRAVER PATE(MMIDOIYYYY) 0511612018 CERTIFICATE OF LIABILITY INSURANCE 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or beendorsed. f SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on :his certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ODUCER CNAMTACT Clure Insurance Agency,Inc. PHONE - FAx 1 Van Deena Ave. (A/c.No,r19-1413).781-8711 (AIC,No)(413)731-8548 ,st Springfield,MA 01089 C&d�S I INSURFJRSIAFFORDING,COVERAGE ) NAIC p MSA Group `29939 URED wsURER s_Safety_Insura__nce Co._ 139454 Sal-Czar Inc.DBA Czar Energy Solutions 1NsuRER c_Associated Employers_Insurance Company 8 Victoria Lavertu 53 North Elm StreetIN-FFIq Westfield,MA 01085 INS_RER_F .� INSURER F )VERAGES CERTIFICATE NUMBER: REVISION NUMBER: 'HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATEO, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS :ERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, _XCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. t ADDL SUBR POLICY EFF -POLICY E%P TYPE OF INSURANCE POLICY NUMBER I LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 F_ _ EACH OCCURRENCE $ -. CLAIMS-MADE rX,OCCUR I DAMAGE TO RENTED 500,000 j BP08686T 03!1012018 03110!2019 - -}. _ ! PRAM{SESfEa-04CUrrpnccJ S f 10,000 MED EXP(Any 011 1150111 E J 1,000,000 PERSONAL R ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER I I GENERAL AGGREGATE !$ 2,000,000 X POLICY['1,C� , _ I LOC I 11 2,000,000 _ ( I I (PRODUCTS•COMPrOP AGG S ( OTHER S AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT I$ 1,000,000 I_ (Ea acct400!) - ANY AUTO 16209399 03/1012018 03/10/2019 4 BODILY V JURY(Per pelson) IS ( DWNED I SCHEDULED ++I j AUTOSONLV Fx AUTOS ( i B_OOILV INJURY(Per accdx��)�5 pip 1111"`` N pVyNgp I I PROPERTY DAMAGE _X_. AUTOS ONLY X, 'A AU70S ONLY I + I I{Per acaderq). 'S I I UMBRELLA LIAR __ OCCUR I I I EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE - i AGGREGATE _ IS DEO RETENTION$ 1 $ WORKERS COMPENSATION I PER AND EMPLOYERS'LIABILITY VIN i _X.. S_TATUiE ER ANY PROPRIETORIPARTNER!EXECUTIVE ( �1 CC5005009831218A 03/2612018 03/2612019 EL EACHACCIDENT I S 100,000 I OFFICER/MEMeER E%CWOEO� `Y NIA 100,000 (Mandatory rn NN) EL DISEASE-EA EMPLOYEE $ It ye I 500,000 DESCRIPTION OF OPERATIONS low E L DIS ASE-POLICY LIMIT �S I ICRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remaras Schedule,may be attached if more space is required) .RTIFICATE HOLDER CANCEIeLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1fr -Vag: .. :ORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD