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15B-036 (11) BP-2024-0405 9 DIMOCK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-036-0O1 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-2024-0405 PERMISSION IS HEREBY GRANTED TO: Project# WOOD STOVE 2024 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: 04/05/2024 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 4."72. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner ,X, City of Northampton t; - ` < Massachusetts 'Ir. ( 1--: '• i !! ? ,e DEPARTMENT OF BUILDING INSPECTIONS y: i� k f'` 212 Main Street • Municipal Building vu.` •ems \�a' ,? Northampton, MA 01060 rPli „6.S•.\ APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION; b r APR - i 52024 ( y Property Information ___ r 7.of►�urr_om%G INSPECTIONS Se+h Cam,lA s+�.1 n L_ ..__ :_"_fr.lf! Owners Name: -• . AMP/ON,Maoinso Address: 9 2,rvloc!L SI-rc,eI- L '.eds n-, ,9 o tas-3 (No.) (Street Address) Phone: ycq- 2(3-l 31g Cell: Email: Se# 5sb co ,,A,., I. c a..., Owners Signature: M Elaz-V c c•--Q Date: ./ /i ig Contractor's Information (If Applicable) Name: 4fGm, I.. W..:‘ . / (11e. Kt.nn.ey Ef-ecitr, hone: qiT-S 36-s`3^s-i Construction Supervisor's License #: ) 0(o )qq Expiration: on/d /2.4:7P.y Home Impr. Contractor License #: 2oc / 3 s- Expiration: oa/o5-1.20c.s-- Stove Information Type of Fuel (check all that apply): Wood Pellet Coal Location: 1 s 1- Poo( Freestanding 7 Insert Manufacturer: Qva.6crA- Fi i.e) Model: Pascovec-t -T-C • ----FOR BUILDING DEPARTMENT USE ONLY------------------------_-_- qO COIL/ 3395 Permit# 31° �'' � 5 ate Applied: • Total all Fees: $ Building Official: (IiL) 72,c Date Issued: q-5-ZOZy (Prizlt7/ — Signature of Building Official: The Commonwealth of Massachusetts _-. Department of Industrial Accidents —,011i tr_= Office of Investigations G. f�! T Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ''�=ium WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):McKenney 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: Type of project(required): 1.❑� I am a employer with 5 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. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' P �' $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 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 right of exemption per MGL g P myself. [No workers' comp. 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no solid fuel appliance install employees. [No workers' 13.0 Other pp comp. insurance required.] *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. tContractors 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 (24) 57 87 2259 Expiration Date:07/2024 Job Site Address: "/�l 1Mo/ACr SAC'. City/State/Zip: 1i2e..49` ykA 01 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 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 rtify(�un�der he pains and penalties of perjury that the information provided above is true and correct Si afore: V \P-- Date: a'I I I 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): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: I, r 11 • I.. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards i It Ems+. Constructj f Specialty I s t CSSL-106199 * ires:0810212024( _ • NORA E WINE' a REDSSELL r. I i' SOUTHAMPTOjt[ lifip' t ?. In al, il, Commissioner --Ar I' 1 i III ,I • I li THE COMMONWEAL-1H OF MASSACHUSETTS 1 Office of Consumer Affair"and Business Regulation 1000 Washing: `,;Suite 710 Bosco 11 g Home imp -strovemerl cborergistratian y �� ( i. w f": I. x, �-__1 t�;\Type: Corporation III iiAC*EtZNL Y ELECTRICAL CO.INC � E '�so: O�tsno25 I;. D/6rA UCKENNEY HEARTH&HOME Fk T:`�= , ; 100 NORTHAMPTON STREET REET V� '— ''" s' i ;I HOLYOKE,MA 01040 �_ �.r�' .. � t i�C �y 4 I'ii vtIli `�It, Update Address and Return Card. I II THE CO ANOWWEALTti OF NiASSACHUSETT3 Office a:Cm:sumer Afraiki,&oosi::ess Reguiaim Renistratim rand for indPdiduai use only izerxa am HOW ao7ROVE6i1EHT•0oN411RACTOR expiration date.If found return to: Office of Consumer Affairs and Business Regulation • g�[sEl____ 1000 Washington Street-Suite 710 Q6, `. SoSton,li9A 02118 MCKENNEY e EC1R8ar :' `=- 17 `er'`g .0! /� f 100 NORTHAMPTON /,11/ Si,,e4.,, peo".* 'Thir\- ,i HOi Y01�MA 01040 v l thotersm-ctary Not valid wRhout signature it I I: II. 11, II, II I !I 0 A., Workers Compensation And Employers Liability Insurance Policy WC 00 00 01 A 11 Coverage Is Provided In: Policy Number: ♦` �� Liberty The Ohio Casualty Insurance Company Policy (24)57 87 22 59 I /� � mutual, Prior Policy Number: INSURANCE IXWO(23)57 87 22 59 I 1 NCCI Co.No. 111363 I •j, Workers Compensation and Employers Liability Insurance Policy I, Information Page 'I ITEM 1:The Insured&Mailing Address Agent Mailing Address&Phone No. I, MCKENNEY ELECTRICAL COMPANY INC (413) 536-0804 T - 100 Northampton St MARTIN J. CLAYTON INSURANCE ' - Holyoke, MA 01040 AGENCY, INC ,1 1649 NORTHAMPTON ST 11. HOLYOKE, MA 01040-1933 1 e Individual Partnership X Corporation or FEIN:XXXXX9517 NAICSx15i140 Other workplaces not shown above: ir' ITEM 2 The policy period is from 07/01/2023 to 07/01/2024 12:01 am StandardTimeat the insured'smailingaddress. i;, ITEM 3 A.Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA 1' B.Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. ilil r The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease $500,000 policy limit , Bodily Injury by Disease $500,000 each employee C.Other States Insurance: Part Three of the policy applies to the states, if any, listed here: See li Extension of Information Page • O.This policy includes these endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 4 The premium for this 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 $100 of Annual Remuneration Remuneration Premium ; i See Extension of Information Page(s) 1` is < Total Estimated Annual Premium n o ,ii� I'' Total Surcharges and Assessments i Minimum Premium MA Total Estimated Cost If indicated below, interim adjustments of premiums shall be made. I' Deposit Premium 3 Countersigned by: Issue Date To report a claim, call your Agent or 1-844-325-2467 WC 00 00 01 A (WC 30 10 E) I © 1987 National Council on Compensation Insurance, Inc. 57872259 POLSVCS 450 INSURED COPY 001673 PAGE 15 OF 48