24D-231 (3) MA Construction Supervisor #CS009989 / MA HIC #148198 / CT HIC,556609
Olde HadleIgh • Hearth & Home Center,. Inc,
119 WIIIImansett Street, So'uth•Hadley, MA 01075 Tel (413) 538.9845, FAX (413) 538.8753
WOOD STOVE INSTALLATION CHECKLIST
Permit
A building permit Is required for the lnstai•iation of any solid fuel burning
appliance, The building permit and Installation Inspection are limited to the
stove installation and' tot to the .stove construction,
Stove
A) Typc /radiant circulating _
8) Manufacturer 'test label
(after July 1 1 979 only)
Name /Model No, Collar size
f)imenslons /Height Length _Width
Chimney
A) New Existing
8) Size (flue area)
C) Other appliances attached to flue (Number and flue s17e)_
D) Metal (Manufacturer --name and type) •
E) Masonry /Lined
Unlined Flue liner
(type & mnnufac.•curer)
r) Neiaht (refer to diagrams) cap
..io I,j \ I a ∎o'
HEARTH
•
CHIMNEY HEIGHT
Hearth(min, l hr, fire resistance) A) Materials
) Sub-floor cons.lrnction ,
C). Minimum dimensions (refer to diagram)
Clearances .and Wa.I'I• •Protect►o'n( see stove InstnflAt'lon clearances chart)
A) Type of wall protect lon..pr.ovIded
8) Clearances (refer to dl•agrams)
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FIREPLACE CORNER WALL /CENTER
•
The Commonwealth of Massachusetts runt roan
4 Department of Industrial Accidents
" ) �` i ___ 4 0 Office of Investigations
Iw ` , 1 Congress Street, Suite 100
, x t —_till ' _ . c r
Boston, MA 02114 -2017
4" ry www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Olde Hadleigh Hearth & Home Center, Inc.
Address :119 Willimansett 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. ❑✓ I am a employer with 8 4. n 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. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no Install wood stove
employees. [No workers' 13. Other
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.
$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
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 Contractors Liscense #148198
Policy # or Self- ins. Lic. #:IEUBB5197B81 Expiration Date: 7/12/2013
Job Site Address: (7` 6 , S City /State /Zip : . 11/Y/71/ : 1 4r lo , /aei
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 I ains and penalties of perjury that the information provided above is true and correct.
Signature: I ' Date
8/10/2012
Phone # -9845 CS SL #9878'
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 #:
City of Northampton
t s
Massachusetts
DEP NT OF BUILDING INSPECTIONS za
t� ��� 12 Street • Municipal Building J
\'0 * orthampton, MA 01060
DEPT EFT
NORTHAMPTON M, 01060
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 # v�
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS Z C) 12 li c 5, / V f2 T7-1 %J0i`-il /v
1. Name of Applicant: 2: vi a ri 2 /,./
Address: "7_ 2 c) /_, c' ea T / ✓` f Telephone: — J 73 7 1 1
2. Owner of Property: art L.✓ /l`, l'1 / /6t �i /G'7 Sc A �7 /Gtl P 6/
Address: 2-2-< /13 C1 f I S f Telephone: // /3 _ ' / 73 L
3. Status of Applicant: > Owner Contractor
4. Type or Brand of Stove: 07 1/(1 (:)c i
Contractor's Name: / jt 1 —' (�, 0
Contractor's Address:
Contractor's Phone: // 3 5 ,3
Construction Supervisor's License Number: 717 Expiration Date: y/. /
Home Improvement Contractor Registration Number: / p c 2 3 / 2. O i
P g � / � 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
of my knowledge.
DATE: APPLICANT'S SIGNATURE
5// 3 +tO1 WNER'S SIGNATUR AP __ - /
•
APPROVED •�
DATE: BUILDING OFFICIAL
220 PROSPECT ST BP- 2013 -0691
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 231 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 -0691
Project # JS- 2013- 001140
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.): 5662.80 Owner: GLOMAN DAVID I & KATHERINE E SCHNEIDER
Zoning: URB(100)/ Applicant: GLOMAN DAVID I & KATHERINE E SCHNEIDER
AT: 220 PROSPECT ST
Applicant Address: Phone: Insurance:
220 PROSPECT ST WC
NORTHAMPTONMA01060 ISSUED ON:1/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL JOTUL 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 1/8/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner