12-023 (11) BP-2022-1231
6 COUNTRY WAY COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12-023-001 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-2022-1231 PERMISSION IS HEREBY GRANTE.P TO:
Project# PELLET STOVE Contractor: License:
Est. Cost:. NORA WINE CSSL-1061 9
Const.Class: Exp.Date:08/24/2024
Use Group: Owner: KWASS, WALTER & ANTRIM, WILLIIAM ASHE
Lot Size (sq.ft.)
MCKENNEY HEARTH&HOME/MCK.NNEY
Zoning: WSP Applicant: ELECTRICAL CO INC
Applicant Address Phone: Insurance:
100 NORTHAMPTON ST (413)586-5351 XWO2257872259
HOLYOKE, MA 01040
ISSUED ON:09/27/2022
TO PERFORM THE FOLLO WING 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 VIOL• TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 111 .
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
, J- L? l '3l
City of Northampton
O
Zie.4.1
'; Massachusetts �,?� '•C'
MI f
ti (} c v S' DEPARTMENT OF BUILDING INSPECTIONS i=; t r�
rd �' 212 Main Street • Municipal Building �.. '•`
N.-' L,,.... Northampton, MA 01060 4:cl g5 �
APPLICATION FOR SOLID FUEL;APPU ANCE INSTALLATION
Property Information SEP 2 7 2022
Owners Name: WA-L W-.. -4 SS
Address: Co C (Du N V,/ 1 ---_,,,A M4 n,o�°IONS
(No.) (Street Address)
Phone:4_03.4 to/.La-- C l: Email: (AK Wu S V r.o__P. c
Date:
Contractor's Information (If Applicable)
Name: f pf.A WINS Phone: y► .CM,.SSS I
Construction Supervisor's License #: CSL- 101,1 l<' Expiration: 21242)1
Home Impr. Contractor License #: 13S Expiration: l lib..b/k
Stove Information /
Type of Fuel (check all that apply): Wood Pellet ✓ Coal
Location: LA V 1 i rk Freestanding Insert
Manufacturer: P4VE1.4 Model: eV- 1 03 CLASS c
•
-- ---------FOR BUILDING DEPARTMENT USE ONLY-------;
t-----_____
Permit# isl Date Applied: Total all Fees: $ I ) al
Building Official: J E Vi ` 0 5 5 _ Date Issued: g' 27- Z02 Z
(Prim)rn?
Signature of Building Official:
,YZ -e—.4„,,,a, ,I.Aar,ieJacieec/),-94-
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
``` - Type: Corporation
! �^ Registration: 200135
KENNE'ELECTRICAL CO.INC. '�x _._
tt NORT 1MPTON STREET '" z"...77.- '_ \"1.\
Expiration: 11/18/2022
/O F.
'�sOL�"OKE,MA 01040 �4 - '�� a)
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''" Update Address and Return Card.
SCA 1 0 20MM--05/17.7/i6 Om/i.4C',tuYel/t/,
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HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corotraimn before the expiration date. If found return to:
aaMM Office of Consumer Affairs and Business Regulation
?1//'512022 1000 Washington Street -Suite 710
IMCKENIEVE _'" ,.0,iC Boston,MA 02118
NORA> ;e� .
TF'J0Mm,'>nr`iA,VPr iCil *�FdE&R o 'a.i'/.ia.,,e,-
iC!y, WA 01040 Not valid without signature
Underseczetagy
Commonwealth of Massachusetts
IFDivision of Professional Licensure
Board of Building Regulations and Standards
ConstructiiorOl ii#E1'pr Specialty
CSSL-106199 fir E tpires:08/02/2024
NORA Eva* v
•RUSSBL 'A
4 '
`4rfti`ft`T.1`�
Commissioner ,% i2. ' u61,Lit�.
t
I
Workers Compensation And Employers Liability lusuriuicc Policy WC 00 00 01 A
Coverage Is Provided In: Policy Nurrber:
\I.:if liberty Tie Ohio Casualty Insurance C.ompanv XWO (23) 57 87 22 59 I
f Mutual. Prior Policy Number:
INSURANCE XWO(22)57 87 22 59
NCCI Co. NO. 11363I
Workers Compensation and
Employers Liability Insurance Policy
Information Page
ITEM 1:The Insured & Mailing Address Agent Mailing Address&Phone No.
- MCKENNEY ELECTRICAL COMPANY INC (413) 53tS-0804
100 Northampton St MARTIN J. CLAYTON INSITRANCE
- Holyoke, MA 01040 AC&FNCY, INC
I(149 NORTHAMPTON ST
,1011.11111110110011
HOT.YI?KF., MA 01040-I 933
_Individual Partnership
X Corporation or FEIN:0,2259517 NAICS:451 1 1ti
Other workplaces not shown above:
ITEM 2 The policy period is from 07101:2022 to 07:1)1/2023 I 2:01 am Standard') imeat the insured'4mailing jdress.
ITEM 3 A.Workers Compensation Insurance: Part One o'the policy applies to the Workers Compensation Law
of the strite5 listed here: MA
B.Employers Liability Insurance: fart Iwo of the policy applies to work in each state listed in Item 3.A.
-, The limts of our liability under Part Two a-e: Bodily Injury by Accident $500,000 each accident
Bodily Injury by Dis,^..aso S500,0D0 policy limit
Bodily Injury by Disease $500,000 each employee
C.Other States Insurance: Part Three of the policy applies tc the states. if ary, listed here: See
Extension of Informat on Page
D.This policy Includes these endorsements and schedules: See Policy Forms and Endorsements Summary
ITEM 4 The premium for the policy will be determined by our fvlanuals of Rules, Classifications, Rates and Rating
Plans.All information required 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
Sec Extension of Information Pagc(s)
Total Estimated Annual Premium
Total Surcharges and Assessments
Minimum Premium MA Total Estimated Cost
I` indicated below, intorirr adjustments of premiums shall bra made_
Deposit Premium
Countersigned by:
Issue Date O5/02:22
To report a claim, cal! your Agent or 4-a44-325-2487
WC 010 00 01 A (WC 311 III E)
19K7 National Council on Compensation Insurance. Inc.
0E02122 57972259 POLSVCS 450 PGXFPPNO INSURED Ur( 0041[4 PAGE, 15 OF 48
` The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
V
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): McKenr.ey 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: 1 Type of project(required):
1.1X 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. 0 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
working for me in any capacity. employees and have workers'
insurance.:
9. ❑Building addition
comp.[No workers' comp. insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 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(2 2)57 87 2259 Expiration Date: 07/2023
Job Site Address: City/State/Zip:
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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):
11:1Board of Health 21:3 Building Department 31:City/Town Clerk 4.1:Electrical Inspector 51D'lumbing
Inspector 6.❑Other _
Contact Person: Phone#: