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23C-098 (12) BP-2023-0651 167 BAKER HILL RD COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 23C-098-001 CITY OF NORTH PTON Permit: Solid Fuel Appliance PERSONS CONTRACTING WITH UNREGI TERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARA TY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0651 PERMISSIO IS HEREBY GRANTJED TO: Project# WOOD STOVE 2023 Contractor: License: Est. Cost: CZAR ENERGY SO UTIONS 103963 Const.Class: Exp.Date: 05/18/202 Use Group: Owner: M. DI:TZ,ROBERT S. & LISA Lot Size (sq.ft.) Zoning: URB Applicant: CZAR NERGY SOLUTIONS Applicant Address Phone: Insurance: 53 N ELM ST 413-642-5641 WCC600983 1 0 1 WESTFIELD, MA 01085 ISSUED ON: 05/19/2023 TO PERFORM THE FOLLOWING WORK: WOOD 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 NORI HAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1 Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissisner City of Northampton ?off- M - _ StS.. Sr '' Massachusetts w ' {� r� IS} R n _'`�._ ,... Mom• *5';,j T j. s, 4 f DEPARTMENT OF BUILDING INSPECTIONS ;`.. e s 212 Main Street • Municipal Building J a \\ �: MAY / 7 Northampton, MA 01060 44; Mn51`�~ 2023 Pcp-i-/ ..„...._ ,,? 3(.j. '''' (99t52 A pq LDING INSp APPL IOWPQRsSOLID FUEL APPLIANCE INSTALLATION Property Information • Owners Name: G-/S� D Address: / ' 7 3///t'C /h/t �2��/qG �r L "/A4- (No.) (Street Address) Phone: - Cell: a k,2-6 t7- 377L Email: ..xf Owners Signature: 7)41i1)/ Date: s ip/ Contractor's Information (IfApplica le) Name: C24e iuc'tiz.C1 c)`u?)nx s Phone: 3//3 S ,3t•- 7/7 f Construction Supervisor's License #: es -f D 3 %4 3 Expiration: C- fit)' - ? Home Impr. Contractor License #: I 3 S�l 6 Expiration: 7 .- 7 - 73 Stove Information Type of Fuel (check all that apply): Wood c/ Pellet Coal Location: -i V/w6 A..9v-A-1 Freestanding Insert L- Manufacturer: A //'/C 61/'U G7 Model: / 2) /, I FOR BUILDING DEPARTMENT USE ONLY-------------------------------- Permit# V-A3 -05 I Date Applied: Total all Fees: $ /—t10 et-14- 6866 Building Official: Date Issued: .5 19/a3 (Prin , i ✓✓✓ Signature of Building Official: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 163596 SAL-CZAR INC. Expiration: 07/07/2023 D/B/A CZAR ENERGY SOLUTIONS 53 N. ELM ST WESTFIELD, MA 01085 Update Address and Return Card. SCA 1 0 20M-05/17 •Alifite f ft54lrtf8r ar1i EleWiiessisiegettition HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: Corporation before the expiration date. If found return to: Registration Expiration Office of Ccnst.ncr Aff/irc nd Business Regulation 163596 07/07/2023 1000 Washington Street -Suite 710 SAL-CZAR INC. Boston,MA 02118 D/B/A CZAR ENERGY SOLUTIONS STACY LAVERTU 53 N ELM ST WESTFIELD,MA 01085 Not valid without signature Undersecretary ?u,2 mp JauotSSIwwo3 c`<<�FA'rfot.� $ L- ;17 ,_98040 VIAI 0131J1S3M .14 flla3Av1 br AWLS SZOZ/21-/SO :saJic(1 £96£0l SD JOSINaf S UO1 3ATsuo3 spJepueiS pue suogeIn as 6uiplm8 to pieoa ainsuaaii leuogednco0 jo uolsuu0 11 sllasngoesseyg to glleamuowwo0 The Commonwealth of Massachusetts 01 1 Department of Industrial Accidents 1 Congress Street,Suite 100 / Boston,MA 02114-2017 • www.mass.gov/dia I.orkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): (C Address: �j - -/ f City/State/Zip: G(-)e- -S"-- 7cCt0,19 Phone#: "7_— j - 2/7 Are you an employer?Check the appropriate box: Qftfd Type of project(required): 1. a employer withemployees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or pa ership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. e / � 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Daffier 152,§1(4),and we have no employees.[No workers'comp.insurance required.] itI/S7t-(/j 3' G//1 02— *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 an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. A� Insurance Company Name: / /J�' l Policy#or Self-ins.Lie.#: 14}{--G COO,j O 3/ .U,) 3/1 Expiration Date: 3 `2 C '2 2 Job Site Address: (o '/�' C/2 `�/L L City/State/Zip: / C, rt 0/1W O/D‘ Attach a copy oft e workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert:;fy er a pat s and penalties of perjury that the information provided above is true and correct. Signature.:/ / Date: J (C, ' -23 Phone#: / /3 . 7l7/ 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �miiii CZARENE-01 JCHOINIERE AcoRE,' CERTIFICATE OF LIABILITY INSURANCE DATEiM �'-� 3N 7/2023YY) 2023 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACTNAME_-__ _._ -------- McClure Insurance Agency,Inc. PHONE ,Ext): (413)781-8711 n/c 103 Van Deene Ave. ,No):(413)731-8548 West Springfield,MA 01089 ADD IL ss_ _ NSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Berkley Specialty Insurance _C--ompan_y 31.295 INSURED INSURER B:Safety_Insurance Co._-_ 39454 Sal-Czar Inc.DBA Czar Energy Solutions INSURER c:Associated Employers Insurance Company_ 11104 &Victoria Lavertu 53 North Elm Street INSURER_D: ; Westfield,MA 01085 INSURER E INSURER F: I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD -IMMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 _ EACH OCCURRENCE $ CLAIMS-MADE L X I OCCUR CGL 0123592-23 3/10/202 3/10/2024 DAMAGETORENTED 300,000 PREMISES(Ea occurrence) .__ $ MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY- $. 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JELQT LOC PRODUCTS COMP/OP AGG $ 2,000,000 OTHER: I $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 4$ 1,000,000 (La accident) ____. -- _ ANY AUTO ___ 6209399 3/10/2023 3/10/2024 BODILY INJURY(Per person, , $ ___— OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) ___.-____ $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE __ $_ I EXCESS LIAB CLAIMS-MADE AGGREGATE __ .'$. - i DED I RETENTION$ i $ C WORKERS COMPENSATION X PER OTH AND EMPLOYERS'LIABILITY .STATUTE _-Eli Y/N WCC50050098312023A 3/26/2023 3/26/2024 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT_._ $-_ OFFICER/MEMBER EXCLUDED? [N I N I A (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE)$ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ' $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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 I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD