35-076 MA Construction Supervisor #C500,9989 #1.48198 / CT H1C,556609
Oide Hadleighv Hearth & Home Center, IRC,
119 Wlllimensett Street, South'Hadley,.MA 01075 Tel (413)'038.9845, FAX (413) 538.8753
WOOD STOVE INSTALLATION CHECKLIST
Permit
A bulIdIng' perm! t is requlred for the 1'nsb Hat I•on of any Rol Id fuel burning
'appliance, The bul 1 d I ng permlt and Insta'1 lot ,Ion ?Inspection Are 1lmlted to the
stove Instal;VatIon• and. hot Co the . stove construction,
Stove e' .
A) Type/radiant' circulating _
8) Manuricturer 'test label
4 (after July T', 1979 only) .
Name /ModeI No Collar slze
r)1mensl ons /HeI ht ,,, Len;gath . Idth "„"� ----'–
Chimney ....
A) New „ ' ExI'st 1hg
8) Size (flue. area)
C) Other app `Ilances hF'tached to; f)ue; Number and flue < sIre)
0) Metal (Manufac=turer—name and type)
E) Masonry /l.Ined '
Unlined 'Flue liner
V(fype . t` in,nnu(ne..tufef)
r) He1oht (refer'' to di agram•,$) .asp:
— 1 -4 '11.77 , , • e. l'
T1,�
ry ,.;\ ,.",.,....
RAM t�FVf1/�f^
■
� I6! HEARTH
•
CHIMNEY HE I'OHT
Hearth (mi 1 hr,, f.Ire re,.siptgn c) A) Haterlsls
g ) S`ub -•f l oor` c'ohl1.C`r n'cC .(n.
C) •' M'l hii mum? d l +me MS' i n'r1's‘ (ro d r' tb:.; d I 8zg r , a ) ,
Clearances .ar,d ' F' ;
IOr I('�ge s't ve , (nstn l'1 : At•'Ior clearances' chart)
A) Type: of ,w,a (1 , n,1•telg ,toLl„..gn'i.,Kkov I ( d, i. ;,,, g •., • :.••
B) c 1 eAcance,s: ( rcfor t,c dte
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Ft0494--:, . . . ,
. 774 , .
1
• F I,REPLACB CORNER WALL. /CENTER
The Commonwealth of Massachusetts (a'd.oS;l,IAW r„r.,,,:j
�, Department of Industrial Accidents
Y —;;, 1.= ' Office of Investigations
Boston, MA 02114 -2017 i
l 1 Congress Street, Suite 100
"'
E � '`y '-`c , www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Prin t. Legibly
Name ( Business /Organization/Individual): Olde Hadleigh Hearth & Home Center, Inc.
r
—
Address:119 Willimansett Street
City /State /Zip: South Hadley, MA 01075 Phone # :4131538 -9845
Are you an employer? Check the appropriate box: Type of project (required):
1. 0 1 am a employer with 8 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
Z. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 1 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ ' 9. ID Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3. ❑ I am a homeowner doing all work MO 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. d other
comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
Tontractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
mployees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and Job site
nformation.
nsurance Company Name: Travelers Insurance Home Improvement Contractor's Liscense #148198
' olicy # or Self -ins. Lic. # :lEUB5197B81 Expiration Date: 7/12/2013
ob Site Address: $ 'Y 4/2i 7 ki7d City /State /Zip: /l/ V/ k , , ? i` Q
,ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to theiimposition of criminal penalties of a
ine 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
f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby certi) under the , ains and ' enalties o i er u that the In ormation provided above is true and correct.
' ► ' Date 8/10/2012 �
ignature: / _—. - -- -
hone # : 538 -9845 CS SL #9878'
Official use only. Do not write in this area, to be completed by City or town offleiaL
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 #:
Massachusetts - Department of Public Safer -.
l ''IT) Board of Building Regulations and Standard
Construction Supervisor Specialty License
License: CS SL 98784
Restricted to SF e. N . 14'` , } '
,. MATTHEW COX ' ' ? i
54 HADLEY STREET
SOUTH HADLEY, MA 01075
"�"'�"" `� Expiration: 4/28/2013
('ttnnnissiunt'1' Tr #: 12985
' Offioe of Consumer Affairs and Business Regulation
r 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
•,Home Improvement Contractor Registration
Registration: 148198
Type: Private Corporation
Expiration: 9/13/2013 Tr# 216476
OLDE HADLEIGH HEARTH & HOME CENT
-
ALAN GOLINSKI __ __ ___
119 WILLIMANSETT STRETT RT 33 - -- — _
S. HADLEY, MA 01075 — _
Update Address and return card. Mark reason for change.
Address 0 Renewal ❑ Employment Lost Card
Al e, 504- 04/04•G101216
;l /ze eolnfmoluoeala o / ,Awvac/ivaetta
-, Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
M ROME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
' Office of Consumer Affairs and Business Regulation
, Registration: 148198 Type:
Private Corporation 10 Park Plaza - Suite 5170
z <' �. E x piration: 9/13/2013 Boston, MA 02116
-DE HADLEIGH HEARTH & HOME CENTER, INC.
AN GOLINSKI
9 WILLIMANSETT STRETT `RT 3 „„,,.,i,—..,..,t53.45,___ — _
HADLEY, MA 01075 Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
=-
= '� =A1=1": Office of Investigations
—'� 600 Washington Street
...1 =.
;: = .=
Boston, MA 02111
www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): •
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. 1 1 I am a general contractor and I 6. n New construction
employees (full and /or part - time).* have hired the sub - contractors
2. n I am a sole proprietor or partner
listed on the attached sheet. 7 • n Remodeling -
ship and have no employees These sub - contractors have 8. 1 Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. n We are a corporation and its 10.n Electrical repairs or additions
required.] officers have exercised their
3. U I am a homeowner doing all work right of exemption per MGL 11.n Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12. Roof repairs
insurance required.] t employees. [No workers' 13.0 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
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 certify under the pains and penalties of peijury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:
e City of Northampton
„� Massachusetts c i
(, DEPARTMENT OF BUILDING INSPECTIONS
,' .:'...V s 212 Main Street • Municipal Building O � /� ��
r G y (3 (�
Northampton, MA 01060 '. ',
DEPT I
O F B UI LDI NG INgPECTlp
N ORTHAM PT ON MA 01G�
,
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 # 200
/v PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS -`I 0 � /1N J&
,1. Name of Applicant: 13 TER, a / L y ( I q
b
Address: "3' gyp LJ ( 7 I Telephone: qi 3 `2 33 1 0
2. Owner of Property: TE K an 3oy I y N N
Address: 5/010.1 Telephone:
3. Status of Applicant: 2c Owner Contractor
4. Type or Brand of Stove: /`i N/ALa Perlal€4
tsJ
Contractor's Name: l dC 2% v (ik j
Contractor's Address: 1 /hay v Y . ` eil t 0/X7 ' ' ` " ` `t /``' Z
Contractor's Phone: /, "' GjO - v 7 � — `
Construction Supervisor's License Number: /O / r5 / Expiration Date: 7 /' ' -12
Home Improvement Contractor Registration Number: / l I Zr Expiration Date: 9/-3/16
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
DATE: r (75/9 HOMEOWNER'S SIGNATURE
." 7""--7' '''' L---"-----------\
APPROVED
DATE: BUILDING OFFICIAL
k '
848 RYAN RD BP- 2013 -0902
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 076 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 -0902
Project # JS- 2013 - 001546
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 17554.68 Owner: YOUNGER -FLYNN JOY & PETER D FLYNN
Zoning: Applicant: YOUNGER -FLYNN JOY & PETER D FLYNN
AT: 848 RYAN RD
Applicant Address: Phone: Insurance:
848 RYAN RD
FLORENCEMA01062 ISSUED ON:4/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL AVALON PENDLETON STOVE
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 4/8/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner