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Ki 7M7
g 4 r 'L
Mirl.3 ft.
t
If the Chimney
nn
extends more
Attic Insulation Shield Q, than 5'above
the roof,you
must install a
Roof Brace Kit.
t
Joist Shield must be installed
when the chimney passes from Install Wall
a lower living space into an
upper living space. Bands at least
every 8'.
Note:You must enclose all t
sections of the chimney when it ^-�-
. passes through accessible living
areas.Selkirk chimney requires
ONLY 2"of clearance to
combustibles. ,�..
Tee requires a
chimney length to
A minimum of go through the
ONLY 6"is wall,and it must
extend a
{ required between minimum of 41/2"
H the Ceiling/Wall and into the room.
Double Wall Stove
o ' Pipe,or 18"for ETj
Single Wall Stove
Pipe.
x'
. ;?).'
Open Weekdays till aturday t<ll 4:00
1kry y
S .
noos�rrws; watis�4+ � Amherst Farmers's The Fire Place Bernardston Farmers
Tasted 8 Clearances to Supply Supply
Product labeled Material Combustibles Warranty PP Y PP Y
co FteavyGauge 413 253-3436 413 397-3463 413 648-9311
Model DSP To Stainless Steel/ Lifetime 320 S.Pleasant St. 106 State Rd. 43 River St.
? � � I UL 5 11 Aluminized 6lnches Warranty
Steel Amherst,MA Whately,MA Bernardston,MA
Single Wall Not Tested LgMfauge 'No
Stove Pipe or Labeled CarYba Steel 18 Inches Warranty ,
*It a wood burning appliance is used every day in the heating c(@us Use Double e Pipe for Optimum Performance
g season,surveys have shown that a single wall stove pipe
LISTED
will need replacement every two or three years.
1 01
Need answers?Call 1.800.433.6341 or visit us online
at www.selwrkcorp.com ,�.� LKIRK.
u... „��
,A ail,
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
A.F.S./DBA BERNARDSTON FARMERS SUPPLY
Address:43 RIVER STREET
City/State/Zip:BERNARDSTON, MA 01337 Phone #:413-648-9311
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 10 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ 1 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'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]' c. 152, §1(4), and we have no
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:PEERLESS INSURANCE
Policy#or Self-ins.Lic.#:WC8165644 Expiration Da,-. q
Job Site Address: /- �i A� City/State/Zip: Perener
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 under the pains any4penalties ofperjury that the information provided above is true and correct.
Si mature. f�i ' 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#•
C�ty of Northampton
Massachusetts
TRIENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 3y fib
w y �ectlons Northampton, MA 01060
060
Elecir�� ,,�1c
h;G,tr�,r
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 # a3 G
3 1
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant'. /<,�111d/r� cS7P�1 rct��l�1� c�cffi��>�1! - IJ0c?!�
Address: `� /�f UpO�/+ jr'f/IQ!'c/ Telephone: Vj--� 6 VPP 1
2. Owner of Property:� �y
Address: /c3 in� 57�� / �6rctlyc- Telephone: 5-,o- -/030
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: 1) POr,50 6 1yi rnSja r)
If applicant is not the homeowner: f
Construction Supervisor's License Number 7q,10j Expiration Date
Home Improvement Contractor Registration Number 16,CSC 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: 3 /6"I APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE w
APPROVED
DATE: BUILDING OFFICIAL
12 PINE ST BP-2014-0968
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A- 182 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-2014-0968
Project# JS-2014-001682
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 9278.28 Owner: PITCHER JEFFERSON&KERI SMITH
Zoning.URB(100)/ Applicant: BERNARDSTON FARMERS SUPPLY
AT. 12 PINE ST
Applicant Address: Phone: Insurance:
43 RIVER ST (413) 648-9311 O WC
BERNARDSTONMA01337 ISSUED ON:312112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL MORSO 6148 WOODSTOVE
W/CHIMNEY
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 3/21/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner