The URL can be used to link to this page

07-062 Office of Consumer-Affair,3 and Business Regulation 10 Park Plaza - S�dte 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 163596 Type: Private Corporation Expiration: 7/8/2015 Tr# 241914 SAL-CAZAR INC. STACY LAVERTU — 53 N. ELM ST ----- ----- ----------------- WESTFIELD, MA 01085 -----��__ _---- -- -------- Update Address and return card.Mark reason for change. SCA 1 Lc 20M-05!11 Address [] Renewal D Employment �! Lost Card ,� n�ti�C��nrn(a�!✓c/uz.�/�(��czlaQC�Cl1e(Y.� OMce of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 163596 Type: Office of Consumer Affairs and Business Regulation xpiration: 7/8/2015 Private Corporation; 10 Park Plaza-Suite 5170 Boston,MA 02116 SAL-CAZAR INC. ENERGY SOLUTIONS S;ACY LAVERTU 53 N. ELM ST WESTFIELD,MA 01085 Undersecretar — Y Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards l.11/1\I/U111111t License: CS-103963 STACY A LAVER0 106 FLORENCE RD EASTHAMPTOI�112 Expiration 05/18/2017 Commissioner ACS '4COR° CERTIFICATE OF LIABILITY INSURANCE DATE 4/9/2 DYYYY) 419/2015 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 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 CONTACT NAME: McClure Insurance Agency,Inc. PNONE (413)781-8711 ac No; (413)731-8548 103 Van Deene Ave. ac No Ext West Springfield,MA 01089 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC k INSURER A:MSA Group INSURED INSURER B:Safety Insurance CO. Sal-Czar Inc.DBA Czar Energy Solutions INSURER C:Associated Employers Insurance Company &Victoria Lavertu —- 53 North Elm Street INSURER D: Westfield,MA 01085 INSURER E: INSURER F: 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER__ MM/DDIYYYY MMlOD1YYVY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR BPO8688T 03/1012015 03/1012016 AMAGE TO D SO,000 PREMISES Ea Occurrence S MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY dECOT- LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO 6209399 03/1012015 03(1012016 BODILY INJURY(Per person) $ 100,000 ALL OW AUTOS NED X SCHEDULED BODILY INJURY(Per accident) $ 300,000 AUTOS X X OwNED DAMAGE HIREDAUTOS $ 100,000 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAB HCLAIMS-MADE AGGREGATE S DED RETEN r1ON$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETORIPARTNERIEXECUTIVE YIN WCC5005OD9831215A 03/2612015 03/26/2016 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 File Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved- ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts nr Department of Industrial Accidents � - Office of Investigations M ! 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aualicant Information Please Print Legibly Name(Business/Organization/Individual): �. Address: 5-3 (�;142 City/State/Zip: 41e Phone#: A;�I yo employer?Check the appropriate box: Type of project(required): 1. /am a employer with 4. [] I am a general contractor and I 6. ❑New construction employees(full and/or p -time)."` have hired the sub-contractors 2.F1 am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have g. 0 Demolition workin for me in an capacity. employees and have workers' g y p � insurance.# 9. E]Building addition [No workers comp.insurance comp. required.] 5. [] We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.5 Other employees.[No workers' 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. tConiractors 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-canters 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: /7 Policy#or Self-ins.Lic.#: � /,]`iT Expiration Date: Job Site Address: "* �` / N7S 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the-pains anAvenaMes ofperjury that the information provided above is true and correct. Si Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ofciat 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#: ci, of Northampton ►`� 3 Massachusetts DE'fARTMENT OF BUILDING INSPECTIONS , eel 212 Main Street • Municipal Building rat+ dye pia Northampton, MA 01060 0 SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS Permit Fee: $25.00 Check# jg D �P`LLEEAAS.,EE TYPE OR PRINT LL INFORMATION 1. Name of Applicant: Address: 7 Telephone: 2. Owner of Property: 06 'y llo %✓� Address: ��• r.I d`z;�r. Telephone: // -3 °'705..--- 3. Status of Applicant: Owner Contractor 4. Type or Brand of Stove: ! Q z 1 Uh f' / (v M ° If applicant is not the homeowner: Construction Supervisor's License Number.C,5 //� ✓ k 3 Expiration Date //4 2-017 Home Improvement Contractor Registration Number / 3 S�1C Expiration Date ;7 ,/1_ -?-614 All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit s. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. r DATE:_ 'S� APPLICANT'S SIGNATURE DATE: HOMEOWNER'S SIGNATURE APPROVED DATE: BUILDING OFFICIAL 357 NORTH FARMS RD BP-2015-1149 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma:Block:07 -062 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-2015-1149 Project# JS-2015-002159 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CZAR ENERGY SOLUTIONS103963 Lot Size(sq.ft.): 23870.88 Owner: ARBEITMAN DAVID A Zoning: RR(100)/WSP(100)/WP(2)/ Applicant: ARBEITMAN DAVID A AT. 357 NORTH FARMS RD Applicant Address: Phone: Insurance: 357 NORTH FARMS RD (413) 313-5705 O WC FLORENCEMA01062 ISSUED ON.512012015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL DUTCHWEST 2461 WOODSTOVE 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 5/20/2015 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner