22D-034 MA Construction Supervisor / C,S,OR9989 / MA H1C #148198 / CT HIC,556609
Ode Hadleigh Hearth & Home Center, Inc
119 WIillmansett Street, South'Hadley, MA 01075 Tel (413) 538.9845, FAX (413) 538.8753
W000 STOVE INSTALLATION CHECKLIST
Permit
A bul Iding perml t I s requl real for the Insta Hat 14n of any sol I d fuel burning
'appli The bul Iding perm)t and instal tat ion :inspection are llmitad to the
stove Instal.ation and' hot t the stove construct !on.
Stove re *
A) Typc /r,dl circulating
8) Manufacturer , # , 'test label
•► ( July T, 1979 only) -
Name /Model No,
Collar size
f)imenslons /Fle'I ht Lengpth Width_ -'
Chimney .
A) New 4 Exl'stlhg ,
8) Size (flue area) •
C) Other appliances attached to flue (Number and flue sire)
0) Metal (Manufacturer --name and type) —.
E) Masonry /Lined,
Unlined Flue Ilner ,_
(type` t mnnu(Ac•turer)
r) Heioht (refer` to diegram,$) cap-
i 1c I ` • : 1
— 1 -4 1, , .777,
/ _
+—� 3.�+0 •1, •ft ►.ii)
»-.( I --+ HEARTH
CHIMNEY HEIGHT
n. s A) Materla�s;
Hearth(
ml 1 IIr, f,lre resistance) hence)
5) Sub-floor dOh3,it' +rctloti ,
C) . M I h'i mum d l m'e MS I CM s ( r=e f a r td d I big r am)
Clearances ' and st ove ,IInstr l`IAlion clearances chart)
A) Type af .V.01- f?ra,Iggg 1SQ.n!iiR(Noimd,�:
1 sl .. :. , -.,_, ,. ..K: . .
s) Cienrances. ( refer to d :bagr.ams )
_____K ::);;pr 7M410110 Tf
X , . —
r
r !REPLACE CORNER WALL /CE14TE11
The Commonwealth of Massachusetts kAtAIIIIM 1
j � b Department of Industrial Accidents
N TA t.. Office of Investigations
1; Congress Street, Suite 100
; - w
- = Boston, M4 02114 -2017
%fie. • 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
r
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. WI 1 am a employer with 8 4. ❑ I am a general contractor and I 6. 0 New construction
employees (full and/or part - time).* have hired the sub- contractors
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 the in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.x 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
_ officers have exercised their 11.0 Plumbing repairs or additions
3. ❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.0 o Install wood stove
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 most 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 Contractor's Liscense #148198
Policy # or Self -ins. Lic. #:IEUB5197B81 Expiration Date: 7/12/2013
Job Site Address: _/ ( City /State /Zip: 1 ///7//0 9 , I V
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 certia under the , ains and , enalties o , er that the in ormatlon provided above Ls true and correct
Si • ature: 1111 kilir ./re..�..,' - -_ 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
i r ._._.
•` r Massachusetts
DEPARTME OF BUILDING INSPECTIONS
'' , i1 ' '. r. ,
• R 2013 212 ain Street • Municipal Building
Northampton, MA 01060 1. ,
l
, N NS
CRTHAIt ,,,,, 01060
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check # 2033
PLEASE TYPE OR PRINT ALL INFORMATION
SI
PROPERTY ADDRESS 1 G rk S4 �` Mk o i o (,2-
• 1. Narpe of Applicant: G I'ev, n e
Address: S _ ) '
O r\ S i - '\- -Ott C..e 1 \\ Telephone 413 � (e, —04 (
� 1 c c)
2. Owner of Property: G 1.4. to ,^ ��y y\' ICIr1°1/4. Pal o, v
Address: Telephone:
3. Status of Applicant:! . Owner Contractor
4. Type or Brand of Stove: — 3 ---. 01–LAN C_gS Vvrte,
Contractor's Name: 0 (.‘,I._ T1 1ike...4\ ae-akts`4\A"
L _ CiblRia, LNc._. 1 Coy
Contractor's Address: 1 1 l U3 I I` t " ,S'2 1 3? szU t j M o
Contractor's Phone: t4 13 S" 1 X 4 0 b II
Construction Supervisor's License Numberr..S SL 981B 'f Expiration Date: y Z$' L3
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
of my knowledge. Olialb
_ Ii
DATE: 31 (g 1 APPLICANT'S SIG ' •
Age
DATE: 3 1 1' l 3 HOMEOWNER'S SIGNATU'• ►
IV
APPROVED
DATE: BUILDING OFFICIAL
51 CLARK ST BP- 2013 -0835
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D - 034 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 -0835
Project # JS- 2013- 001437
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.): 58806.00 Owner: FAGEN GLENN S & DIANA L AJJAN
Zoning: URA(100)/WSP(100)/ Applicant: FAGEN GLENN S & DIANA L AJJAN
AT: 51 CLARK ST
Applicant Address: Phone: Insurance:
51 CLARK ST O 586 - 0469 () WC
FLORENCEMA01062 ISSUED ON:3/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL JOTUL CASTINE 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 3/18/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner