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04-012 (4) BP-2024-0444 734 KENNEDY RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 04-012-001 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-2024-0444 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 HALL,FRANCES ERICA&EDWARDS, DAVID Use Group: Owner: DYAN Lot Size (sq.ft.) MCKENNEY HEARTH&HOME/MCKENNEY Zoning: WSP Applicant: ELECTRICAL CO INC Applicant Address Phone: Insurance: 100 NORTHAMPTON ST (413)586-5351 XWO2257872259 HOLYOKE, MA 01040 ISSUED ON: 04/17/2024 TO PERFORM THE FOLLOWING WORK: FREESTANDING 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: 17-Z. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner City of Northampton-__. V ,'�,,- :.. � Z Massachusetts w�S' r�'I APR 1 6 2024 ,y * 4. 1 f DEPARTMENT OF BUILDING'INS P CTIONS �'. "+ '' ' " �;` 212 Main Street • Municipal BW - v,� .�e \\! a: Northapton, MA =66 T ,4a -__i ssi%"� 11`�� fUiLDING MSPECTIONS `�NC�R7 _,..ON.MA 01060 APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: j ,,,,.A ._.w .1S Address: "3-3 9 g cr,r,e.A y Roc.. L e•e s m 6 Givs 3 (No.) (Street Address) Phone: S'o3_ 614o-13s-/ Cell: Email: • Owners Signature ql.."_/ ri tsvi c c Date: 1-F13)./ Y Contractor's Information (If Applicable) Name:,ti,ft- L,„F/flit Xt„neti t/ecfr'c Phone: y)3-s-36 --Ss-s-/ Construction Supervisor's License #: )04l9c1 Expiration: otlo?'l/o2cf Home Impr. Contractor License #: 2cv)3S Expiration: cAlas/2.oAs-- Stove Information Type of Fuel (check all that apply): Wood / Pellet Coal Location: c„4. feo( Freestanding V Insert Manufacturer: yea..{ihSIon e Model: fv)c ..1 c 1 e y i e ----FOR BUILDING DEPARTMENT USE ONLY 1".I 1r) ctt'q3iiil Permit# 70'#-, IP& Date Applied: � Total all Fees: $ Ct Building Official: / u►r...) Zx Date Issued: q-17-ZOZy (Print) Signature of Building Official: 4//47 r ;, Commonwealth of Massachusetts 1 Division of Professional Licensure Board of Building Regulations and Standards i Constructs 5•'0 'rVt`Spr Specialty I CSSL-106199 Epires:08/02/2024 i .. • NORA E WINE 8 RUSSELLVILLE RD Y l iiii !' SOUTHAMPTON MA 01073 i `>, t v()IS5=1:10.- /p i i �s i Commissioner Ga K. &,t iI • ill THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affai s and Business Regulation 1000 Washing tct-Suite 710 BostonBostonMassadattsetfs=82118 Home Im�roveme ep tration r^t ''),V t„, Type: Corporation • bon: 200135 MCKENNEY ELECTRICAL CO,INC } 'ration: 02/05/2025 • D/B/A MCKENNEY HEARTH&HOME ":. 100 NORTHAMPTON STREET , HOLYOKE,MA 01040 II 4 CTr• v Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS ;;,p Office of Consumer Affairs.&Business Regulation Registration vatic for individual use only befora tic 'ail 111 HOME IMPROVEMENT'CONTRACTOR expiration date. If found return to: TYPEi.tOiteta0en Office of Consumer Affairs and Business Regulation Registfa;ici lion 1000 Washington Street-Suite 710 Boston,MA 02118 MCKENNEY ELECTRIC _ C — - OBIA MCKENNEY H OLIE-_' = i . - :_.. _�� . NORA WINE (1 _ �_�, 100 NORTHAMPTON 5T.f2EE -,/,„'"9,......ea-i�iLlrYk v HOLYOKE,MA 01040 T� .,,_�• ii Undersecretary Not valid without signature . The Commonwealth of Massachusetts IrDepartment of Industrial Accidents Ojce of Investigations Lafayette City Center2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia i 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/Zi.: Holyoke,_MA 01040 Phone#: (413) 536-5551 Are you an employer? Check the appropriate WI: 1 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. 0 Remodeling These sub-contractors have ship and have no employees 8. ❑Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑Building addition [No workers' comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.❑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 insurance required.]t c. 152,§1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.®Other Solid Fuel comp.insurance required.] appliance install ,j "Any applicant that checks box f I 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, 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 ,,ii employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. iii 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: 07/2021 Job Site Address:13cl K(Gnne,1 Ro. S. City/State/Zip: Let ds r t0 0103'3 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 1I 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.rertfi,under the pains and penalties of perjury that the information provid d above is true and correct. Signature — ✓L Date: If�3'.Z-1 Phone#: (413) 536-5551 Officialuse only.J1" n Do not write in this area,to be completed by city or town official ,j Ji City or Town: Permit/License# - Issuing Authority(check one): IdBoard of Health 20 Building Department 3fCity/Town Clerk 4.0 Electrical Inspector sDPlumbing Inspector 6.0Other Contact Person: Phone#: Wurkors Coinpcusatiou And linpluycn Liability Ltsunwvc Policy WC 00'00 01 A Coverage Is Provided In:VPolley Number: 1 Liberty The Ohio Casualty Insurance Company XWO(24)57 87 22 59 I , r. Mutual. Prior Policy Number: INSURANCE XWO(28)57 87 22 59 I NCCI Co. No 113631 i Workers Compensation and Employers Liability Insurance Policy ., Information Page I ,1' 111BIII 1:the Insured 8 Mailing Address meat Mailing Address&Phone No. BE Eno MCKE TIP Y F.LFCTRIC:\L COMPANY NC (413) 536-()804 ME 100 Northampton St MARTIN I. CLAYTON INSURANCE MI Holyoke, MA 01040 II AGENCY. INC I 649 NORTHAMPTON ST y.i HOT.YOKE- MA 01040-1 9a3 1 _Individual _Partnership X CMEIorporation or FEIN:XXXXX9517 NAIC8:451140 Other workplaces not shown abed,: ®u'a ITEM 2 The policy period is rixim 0i:0i/2(t23 to 0710112024 12:01 am Standard'I imeat the inswed'snutilingaddress. Tiff - ITEM 3 A.Workers Cnmpensatlen insurance: Part One o'the policy applies to the 'Jdorkers Compensation Law „' ,wf thro lif:;tes, listed he re'.: ft1A 9.Employers Liability Insurance; (-'tart Iwo of the policy applies to work in each state listed in !tern ;3.A. ?he Units of our liability under Part Two a'e: Bodily Injury by Accident S500,000 each accident Bodily Injury by Disoaso S500,000 policy limit 1 Bodily Injury by Disease S500,000 each employee C.Other States insurance:. fart Three of the policy applies tc the states. if ary, listed here:See Extension of Interim-It on Page, III.This policy Includes these endorsements and schedules: See Policy Fortrs and Endorsements Summary ITEM 4 The pramiurtt far the 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 $190 of Annual Remuneration Remuneration Premium See Extension of Information Page(s) 1 ;, Total Estimated Annual Premium 1j Total Surcharges and Assessments Minimum Premium $312.00 MA Total Estimated Cost l'indicated below, interim adjustments of premiums shall ho made. Deposit Premium II i Countersigned by: Issue Date To report a claim, cal! your Agent or 1-8t4-325-2187 WC 00 00 01 A (WC 311 III E) I 9K7 National Council on Compensation Insurance. Inc. i7572255 POLSVCS 450 INSURED CCP? 001673 PAGE 15 OF 48