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23D-152 146 HINCKLEY ST BP-2017-0212 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:23D- 152 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-2017-0212 Project# JS-2017-000361 Est. Cost:$3000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo THE FIRE PLACE 99401 Lot Size(sq. ft.): 22041.36 Owner: HENSON ROBERT.'& SUSAN C Zoning: URB(100)/ Applicant: THE FIRE PLACE AT: 146 HINCKLEY ST Applicant Address: Phone: Insurance: P O BOX 606 (413) 397-3463 0 WC WHATELYMA01093 ISSUED ON:8/17/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL LOPI ROCKPORT 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 8/17/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I; } DEPARTMENT OF BUILDING INSPECTIONS i, 5 -� 212 Main Street • Municipal Building %XV r %fotaitiaMiu RI1�I`CFfVRD Northampton, MA 01060 AUG I r 2OIG DER CF BJ.DRG INSPECnONg NOPTKAMPr c • I FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN,STRAW OR SIMILAR STOVES,OR FIREPLACES Check# /697.6 Please WI in all appropriate information 1. Name of Applicant: r= %07 / Ydbbjr c. Address: 75- /,&rrri 3-/ (�ranby MP Of 3-7 Telephone: r//3 377 3`/6:3 2. Owner of Property : john /Jerson Address: I V% /}/nticy ,S4 f/OYC/CQ Telephone: 3. Status of Applicant: Owner Contractor d- Type or Brand of Stove : Lop; eackincr/ //POO %"foVC 5. Estimated Cost : 4 3obe. — If applicant is not the homeowner:: Contractor name 1)009 L/1“-cC - 7;1 F/eSP/c''2 Construction Supervisor's License Number 97110/ Expiration Date J/ l Home Improvement Contractor Registration Number /?OY77 Expiration Date 7/- 7?-4. All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 6. Certification: I hearby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: r//6 Jt'6 APPLICANTS SIGNATURE \� /,tD DATE: 8//3//6 HOMEOWNER'S SIGNATURE/. sI M0 APPROVED DATE: BUILDING OFFICIAL The Commonwealth of Massachusetts Department of Industrial Accidents Office Investigations I Congressss Street, Suitete 100 'tom Boston, MA 02114-2017 "ymg www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): THE FIRE PLACE Address:106 STATE RD City/State/Zip:WHATELY, MA 01093 Phone#:413-397-3463 Are you an employer? Check the appropriate box: Type of project(required): I.1 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. ❑ New construction 2.❑ I am a sole proprietor orpartner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have y ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 70.0 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.❑ Roof repairs insurance required.] ' c. 152, §I(4),and we have no 13.0 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box PI must also fill our the section below showing their workers'compensation policy information. 'Homeowners who submit this afhdarii indicating they are doing all work and then hire outside contractors must submit a new afldavii 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 employes. 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:MA RETAIL MERCHANTS WC GROUP INC. Policy#or Self-ins. Lic. 4:014005033601116 Expiration Date:1-1-2017 Job Site Address: l 516 W(-vx-r�.z. .S/— City/State/Zip: P0/enKA 0/06 02 r 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 S250.00 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 and nnaalties of perjury that the information provided above is true and correct. g G ltDate: 8' /6-4Si nature: Phone#: 413-397-3463 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): I. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Stove Installation (for qualified installers only) 9 Typical Flue Center MI 125'765mmeeTTi Top View - sear wee Straight Installation roearanea) seam e, Typical Flue Ccoter Qa Mum L,NT FFFF GQ S lewa 21 IStcmmt � ReducedClearance ls Ts taalmn,l ! ante of"'. t\ Iaea= nce G1 InmAlNOTE vent Sweeter clearaV F brand m clearamH ITS Measure rear and side clearmcoe from Mem?Protection \ the nearnt edge of sloe by Meawre front dnwicea Tem to face of the stove(doer openttryyl Figure 2 Top View- Corner Installation 'n`aFlue Cate? 225- Clearance F ! Clearance 0: C} 1 L t bf r rN t 1 e • \ NOTE vent dxmeter may very (., dependigon oracv ands Se rc noef) w A e: r s Measure rear and side dearances atom 1 I Floor Fronton N The nearest edge of the stove top. Measure front clearances from Me face of Me stove Men,cpevirg} Figure 3 C Travis Industries 100-01431 4141008