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
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EIVED O f e of Investigations
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C ,, \;: . ';, FEB i 3 2012 ost ► n, MA 02114 -2017
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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
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, u . e�.. E EIVED M: ssachusetts
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` 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