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
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seam e,
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� ReducedClearance ls Ts taalmn,l
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t\ Iaea= nce G1
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m
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ITS Measure rear and side clearmcoe from
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face of the stove(doer openttryyl
Figure 2
Top View-
Corner Installation 'n`aFlue Cate?
225-
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r s Measure rear and side dearances atom
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Measure front clearances from Me
face of Me stove Men,cpevirg}
Figure 3
C Travis Industries 100-01431 4141008