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29-459 MA Construction Supervisor #CS009989 / MA HIC #148198 / CT HIC;°556609 Olde Hadleigh' Hearth & Home Center, Inc. 119 Willimansett Street, South•Hadley, MA 01075 Tel (413) 538.9845, FAX (413) 538 -8753 WOOD STOVE INSTALLATION CHECKLIST Permit A building permit is required for the I•nstallatlon of any Solid fuel burning appliance, The bullding permit and installation inspection are limited to the stove installation and'not to the stove construction, Stove ,' • A) Typc /radiant circulating _— B) Manufacturer 'test label 4 (after July I, 1 979 only) Name /Model No. Collar size Dimensions /Height Length Width , Chimney A) New Exi'St ing 8) Size (Flue area) C) Other appliances attached to flue (Number and flue D) Metal (Manufacturer- -name and type) • E) Masonry /Lined Unlined Flue liner (type c mnnufacturer) F) Height (refer to diagrams) cap N N — - 7 - T.. , --- 1 - - . T7 - 7. - .7, . \ , , ..... s',,,, *IriTr—i- ,, 4 i ,, , ii , . , , .„.. . 4,, 115 ",,,,,, mem , � HEARTH t_.t 4, CHIMNEY HE IGHT Sub - f Hearth(min. I lir, fire resistance) A) lats• 8) Sub floor cons.t ruct ion • C) ' Minimum dimensions (refer to diagram) Clearances .and Protection( see stove installation clearances chart) A) Type of wall protection..provided 8) Clearances (refer to diagrams) ..--, . 14--44 4 • • , 4-44 • 4 FIREPLACE CORNER WALL /CENTER s The Commonwealth of Massachusetts I Print Form A-- RE 1 _ De artment of Industrial Accidents i� Y � � �� EIVED O f e of Investigations li.-7- . II .. 1= , l 1 Ion! ress Street, Suite 100 mo w_ , i r� C ,, \;: . ';, FEB i 3 2012 ost ► n, MA 02114 -2017 ■ {` r �k< w w.mass.gov /dia Workers' Co peJ ».'; :';r l rt A ti idavit: Builders / Contractors /Electricians/Plumbers Applicant Informa ion Please Print Legibly Naive ( Business /Organization/Individual): Olde Hadleigh Hearth & Home Center, Inc. P Address: 119 W'illimansett Street City /State /Zip: South Hadley, MA 01075 Phone #: 413/538 -9845 Are you an employer? Check the appropriate box: Type of project (required): 1. El I am a employer with 8 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. El New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition for me in any capacity. employees and have workers' working Y P ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance. ] . re uired 5. 0 We are a corporation and its 10.0 Electrical repairs or additions q officers have their repairs or additions 3. ❑ I am a homeowner doing. all work ave exerc r 11. ❑ Plumbing re P myself, [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no Install wood stove employees. [No workers' 13. Fd Other comp. insurance required.] "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. l 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: Travelers Insurance Home Improvement Contractor's License # 148198 Policy # or Self -ins. Lic. #: IEUB5197B81 Expiration Date: 7/12/2012 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi� fy under the pains ' nd penalties of perjury that the information provided above is true and correct. Si t ature: ' . L .'' ` — _ — — — — Date 11/11/2011 Phone # ' 538 - 9845 CS SL #98784 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 #: f City of Northampton 0ii:rr r . , u . e�.. E EIVED M: ssachusetts r ` f . #, FEB 3 2 1 NT OF BUILDING INSPECTIONS .1 a � t' _ n S reet • Municipal Building IliS No• hampton, MA 01060 � DEPT OF BUILDING INSPECTIONS NO RTHAMPTON, MA 07060 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 # O 5 0 PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: i r I € v 3U s (I L Address:1 \ CreSfv'av3 0 f Telephone` 3— 3'1 3 S S 2. Owner of Property:S Pi4Xl -}- AII' P:v 0 1 \) IIt \)GAn r Address: - 74-1 CrQS +v\ .,\.)J r Telephone: 1 3\ r''' S ,.._ y 5 un '`e'� 3. Status of Applicant: r Owner Contractor �r �i - } - �Zq P�� 1 4. Type or Brand of Stove: . �J t Ore ', r� ■.") (A > J`� h..i If applicant is not the homeowner: Construction Supervisor's License Number Expiration Date Home Improvement Contractor Registration Number Expiration Date 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 y of my knowledge. DATE:1 c 2 - CZ} APPLICANT'S SIGNATURE �.;� -11\-� _Z C - Q9,.....,%• ---° ri ' DATE: �`+- - 2- r Li HOMEOWNER'S SIGNATURE �`-t.Y - \, ,,, ___- APPROVED , , a`"l ""'� \� - ;"s' ' - L., DATE: BUILDING OFFICIAL 71 CRESTVIEW DR BP- 2012 -0712 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 459 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Penn1!: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit # BP- 2012 -0712 Project # JS- 2012 - 001256 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784 Lot Size(sq. ft.): 10018.80 Owner: MONAHAN LORI K CIO STEPHEN O'SULLIVAN Zoning: URA(100) //WSP Applicant: MONAHAN LORI K C/O STEPHEN O'SULLIVAN AT: 71 CRESTVIEW DR Applicant Address: Phone: Insurance: 71 CRESTVIEW DR WC FLORENCEMA01062 ISSUED ON:2/15/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL AVALON 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 2/15/2012 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner