The URL can be used to link to this page

15B-036 (10) BP-2024-0079 9 DIMOCK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-036-001 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-2024-0079 PERMISSION IS HEREBY GRANTED TO: Project# 2024 WOOD STOVE Contractor: License: Est.Cost: 0 NORA WINE CSSL-106199 Const.Class: Exp.Date:08/24/2024 Use Group: Owner: CARRIE GOLDSTEIN SETH B& Lot Size(sq.ft.) MCKENNEY HEARTH&HOME/MCKENNEY Zoning: URA Applicant: ELECTRICAL CO INC Applicant Address Phone: Insurance: 100 NORTHAMPTON ST (413)586-5351 XWO2257872259 HOLYOKE,MA 01040 ISSUED ON: 01/26/2024 TO PERFORM THE FOLLOWING WORK: INSTALL WOOD STOVE INSERT ON 1ST FLOOR 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: v� ., . -ikT Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner I5S-O3e-not City of Northampton Dr9 • + M' S`s ..w .CMG � 4 � " ,-'1 Massachusetts f ;1� /.. • F. * -G. I Yk' M :14 :�. CFI t �1 1 y,4} ' DEPARTMENT OF BUILDING INSPECTIONS ,� -:k : 212 Main Street • Municipal Building J4, C` \\, Northampton, MA 01060 '�s7%n-;;;:S1`� } APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: 5 e -1) G-0 J ASI-e 1 ti Address: cl D, v.,c,cie. 5 c-e 1- LeQAs lAi r9 0Ia53 (No.) (Street Address) Phone: 954/- G 3-i,let Cell: Email: Owners Signature:l\09L 6nS-1 k11ae-1 Date: ic \S)..)-1 Contractor's Information (If Applicable) Name:,'/a I- LJ,;, -e_Altke„net fl•ec/rrc Phone: ,Ji3-5'36 -sss'1 Construction Supervisor's License #: ici,M q Expiration: afr/0 /x),(..l Home Impr. Contractor License #: xoj 3.f Expiration: oW/os/�os- Stove Information Type of Fuel (check all that apply): Wood ✓ Pellet Coal Location: rs-4 C) . ( Freestanding Insert cV" Manufacturer: Q,,..2t rc,- jam,r-e- Model: (),.sc Gver/ -I - L ----FOR BUILDING DEPARTMENT USE ONLY------------------------ Permit#t3P-- o2 -00-71 Date Applied: Total all Fees: $ 4'� Z l"D q J3')- 1 Building Official: 4-.0i kJ I�Q73 Date Issued: I-2/...• 2oz Li (Print) Signature of Building Official: Commonwealth of i111assachusetts Division of Professional Licensure !iI Board of Building Regulations and Standards II, Construct CMSixp rcnspr Specialty '!' CSSL-106199 li �7c�p i res:0 8/02/2024 NORA E WINS" - . 8 RUSSELLVILLE RD 7. --.ad. f SOUTHAMPTON MA 01073 .r i Commissioner } ?, d&i a ,i) • 1 THE COMMONWEALTH OF MASSACHUSETTS 1 Office of Consumer Affai"atad Business Regulation 1000 Washingtac\t,-Suite 710 Bosto 118 i Home Im srovemt=t egitration r ^t y,I Type: Corporation egisttation: 200135 MCKENNEY ELECTRICAL CO.INC ..._ Extiation: 02/05/2025 DB/A MCKENNEY HEARTH&HOME 100 NORTHAMPTON STREET Ft.) HOLYOKE.MA 01040 kci Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs.&Business Regulation Registration valid for indi•:Idual use only before the 11 HOME IMPROVEM NTCONTRACTOR expiration date. If found return to: �M r.,r i TYPE tion Office of Consumer Affairs and Business Regulation �p Rstreddtf= - 1000 Washington Street-Suite 710 2QO,t3 r"—.- 025 Boston,MA 02118 MCKENNEY ELECTRIC. 0lB/A MCKENNEY HF }i25G£__ L_______ . NORA WINE ; 9 �, LF. 100 NORTHAMPTON i ..... ��%,,• 1 G/24 1 HOLYOKE,MA 01040Undersecretary Not valid without signature I' 1•� II G I .I li The Commonwealth of Massachusetts ii Department of Industrial Accidents 7 SE�AV— Office of Investigations z. .1_I-1 �' Lafayette City Center _.._� 2 Avenue 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): McKenrey Electrical-Co. Inc. - Address: 100 Northampton Street il City State!Zip: Holyoke, MA 01040 Phone#: (413) 536-5551 Are you an employer? Check the appropriate box: Type of project(required): 1.© I am a employer with 4 4. ❑ I 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. ❑Remodeling shipand have no employees These sub-contractors have 8. El Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. El Building addition required.] 5. ❑ 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 ii 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. I"HomEowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. CContractors 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: 07/202`f • Job Site Address: 41 Dt wt ode_ 5 f re.e-+ City/State/Zip: L e e�S Wl s9 0I05-3 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 2SA of MGL c. 152 can lead to the imposition of criminal penalties of a 1 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 ce a under the pains and penalties of perjury that the information provided above is true and correct. Sir ��l9 nature� t Date: 1 4)-- 1)--1{ Phone#: (413) 536-5551 Official use only. Do not write in this area,to be completed by city or town official 1 City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:1City/Town Clerk 4.DElectrical Inspector 51:3Plumbing Inspector 6.DOther Contact Person: Phone#: Ir Wurkcrs Cotnpcusutiuu And Ltnplutcr_ LitlbiliLy lusurturcc Police' WC' 00'00 01 A li Coverage is Provided IrvPolicy Number. Liberty Tie Ohio Casualty Ins�ranoe Company (24)57 87 22 59 I Mutual. Prior Policy Number: INSURANCE XWO(23)57 87 22 59 Nccl Co.No. 11363 1 Workers Compensation and Employers Liability insurance Policy information Page • imamsITEM 1:The inured&Mailing Address Agent Mailing Address&Phone No. NICK ENNEY F.LF.CTRICAL COMPANY NC (413) 536-0804 MEW100 Northampton St MARTIN T. CLAYTON INSI?RANCR Holyoke, MA 01040 AGENCY. INC immo I(649 NORTHAMPTON ST s� HOT.YOKE. MA 01040_1933 iii Individual Partnership X Corporation or FEIN:X?{XX?C951 ` NAll:ss151]4U Other workplaces not shown oboes: mama ITEM 2 The polity period is iron 07101:2C113 to 07/01 202 4 12:01 am Standard'I imeat the insured':•;mailingN4dress. ITEM 3 A..Workers Compensation insurance: Part One o the policy applies to the Workers Compensation Law n1 lh. yl ita; lislr;,d here: M B.EiRpleyers Liability Insurance: Part Iwo of the policy applies to work in each state listed in Item 3.A. The hails of our liability under Part Two n'e: Bodily Injury by Accident S500,000 each accident Bodily Injury by Disoaso S500.000 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 Informaton Page D.This policy Includes these endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 4 The premium for th s 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 Rate per Estimated No. Estimated Annual $180 of Annual Remuneration Remuneration Premium Scc Extension of Information Paae(c) Total Estimated Annual Premium 1 Total Surcharges and Assessments i Minimum Premium $312.00 MA Total Estimated Cost 1' indicatod below_ intorin' adjustmonts of prnmiums shall ho made. Deposit Premium Countersigned by: Issue Date To report a claim, call your Agent or 4-844-325-2187 WC 00 00 01 A (WC 311 Ill E) 19E17 National Council cm Compensation Insurance. Inc. 579722E9 POLSVCS 450 INS11ftED CCPY 001673 PAGE 15 OF 48