43-070 MAR - 18- 2013 10:09 FINICK & PERRAS 1 413 527 5970 P.001-'001
E1SZVr'CA.! I. tk 1 It"II•H 1 C V[ LIHDILI 1 1 IIVaUF b%IVUG I 03/18/2013
PRODUCER (413)527 -5520 FAX (413) 527 - 5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
6 Campus Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Easthampton, MA 01027
El i zabeth Wildman INSURERS AFFORDING COVERAGE NAIC #
INSURED Richard Scott INSURER A: Main Street America AsSr Co 29939
20 BULLARD AVE INSURER B:
HOLYOKE, MA 01040 -1304 INSURER C:
INSURER D. --
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT, 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AOD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
I TR WIRE. DATF (MMIDD/YYl DATE [MM /DrNYY1 LIMITS
GENERAL LIABILITY MPT51820 02 0 2 / 14/201 4 EACH OCCURRENCE $ 1,000,000
COMMERCIAL GENERAL LIABILITY DAMAGE 'r0 RENTED 500 000
� r. EPCMISFS (Fa rr irwnra) $ ,
CLAIMS MADE X OCCUR MED EXP (Any one person) 3 10,000
A x PERSONAL R ADV INJURY $ 1,000,000
GENERAL AGCRECATE $ 2,000, 000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OPACG $ 2,000 000
POLICY LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
(Ea accideot)
ALL OWNED AUTOS
BODILY INJURY $
SCI4EDULED AUTOS (Per person}
HIRED AUTOS
BODILY INJURY
$
NON•OWNCD AUTOS (Per accident)
PROPERTY DAMAGE $
(Per occident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO V EA ACC 3
OTHER THAN
AUTO ONLY: AGG 3
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR ! CLAIM* MADE AGGREGATE $
DEDUCTIBLE
RETENTION $
C $TATU• OTH•
WORKERS COMPENSATION AND 1 T LIMITS I 1 FR
EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNERJEXECUTIVE C.L. EACH ACCIDENT 3
OFFICER/MEMBER EXCLUDED? E,L DISEASE • U EMPLOYEE $
If yes, describe under ^^^
SPECIAL PROVISIONS below C.L. DISEASE - POLICY LIMIT &
OTHER
DESCRIPTION OP OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Proof of coverage
CERTIFICATE HOLDER - CANCELLATl¢N ,.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
McKenney Electric AUTHORIZED REPRESENTATIVE 1.0-0 � __�
Elizabeth Wildman BETH [� iruu�v
ACORD 25 (2001108) FAX: (413) 534 -1182 OACORD CORPORATION 1988
TOTAL P.001
A The Commonwealth of Massachusetts
=me = Department of Industrial Accidents
1, r — ft Off ce of Investigations
�� 600 Washington Street
• ...., = Boston, MA 02111
S OW ww w.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print LeEibly
Name ( Business /Organization/Individual): R 1 C-) L Pt l< .l SCD TT
Address: _ 0 12 0 L L a te- 4 e- /---1()., y 0 K
City /State/Zip: )II S J 0 lb 1 b Phone #: y 13 6. V
Are you an employer? Check the appropriate box: Type of project (required):
I. n 1 am a employer with 4. ❑ 1 am a general contractor and I
e loyees (full and/or part -time).
have hired the sub - contractors 6. ❑ New construction
2. am a sole pioprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship nd have no employees These sub - contractors have
p 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
t 9. ❑ 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 1 1 . L 1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.1:11 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no I3.❑ Other g
employees. [No workers'
comp. insurance required.) n p A - 1. L
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 that 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:
Policy it or Self -ins. Lic. #: Expiration Date: - O - t -
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 maybe forwarded to the Office of
investigations of the DIA for insurance coverage verification. _
1 do hereby certify under the pa' • s and penalties of perjury that the information provided above is true and correct.
Signature: ' • Sz Date: _
Phone #:
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
t
r
City of Northampton
Ma ssach usetts
Al'„ :' Y ECEIVED �. -,
i D PARTMENT OF BUILDING INSPECTIONS 1
� ;7: � - 12 Main Street • Municipal Building f= -'`
,- 9 an Northampton, MA 01060
, DEPT. OF BUILDING INSPECTIONS
NORTHAMPTON MA 01060
SINGLE OR TW • A 1 ILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check #,� 9.'
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS ! �P Q
f
1. Name of Applicant: l)irvIf) /_ ( /6,4'.F ,
Address: n U4'/ 11 1 i) Q,_ }mac 1,.PNoe (41)). Telephone: S - r( -- j //
2. Owner of Property: 1)L} yip �I P , I c. , a � o
Address: £7(: 61am4 -el,i K.)4'141- .J rzioae4J(F P14 Telephone / 3 ) C? -_317 .2-
cA
3. Status of Applicant: Owner Contractor t
4. Type or Brand of Stove: id CAT / t . —
Contractor's Name: R iC hQ f'CI Sco
Contractor's Address: 2 ,0 B x..I 1 2 r(1 s � / ., 14 o f c re , m r J 0 i n�c)
Contractor's Phone: 'i 3 . 4'16 ICJ OCk ,
Construction Supervisor's License Number: R3 10E3 Expiration Date: e - 1 4 - 20 t4
Home Improvement Contractor Registration Number: /&0 6,,9 Expiration Date: 08 08 ZD I
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
-9
DATE: / - / APPLICANT'S SIGNATURE pi------
DATE: / Q -
(,f p7 O -3 HOMEOWNER'S SIGNATURE c
APPROVED
DATE: BUILDING OFFICIAL
96 DUNPHY DR BP- 2013 -0921
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 - 070 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2013 -0921
Project # JS- 2013- 001566
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 16030.08 Owner: BICKFORD DAVID L & JANE E
Zoning: Applicant: BICKFORD DAVID L & JANE E
AT: 96 DUNPHY DR
Applicant Address: Phone: Insurance:
96 DUNPHY DR
FLORENCEMA01062 ISSUED ON:4/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL HEATILATOR WS - 22 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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/9/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner