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_4 Office of Consumer Affairs and Business Regulation
'='ir=it 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.
0 Address Renewal U Employment ❑ Lost Card
cm 0 50M•04/04•G01012166 /^/ // /
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=\ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only
__ before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR
'�_= Registration: 148198 Type; Office of Consumer Affairs and Business Regulation
_% = 10 Park Plaza-Suite 5170
-" Explration; 9/13/2013 Private Corporation
,;,mss;, ' Boston,MA 02116
)LDE HADLEIGH HEARTH&HOME CENTER, INC.
\LAN GOLINSKI
19 WILLIMANSETT STRETT RT 3 :„„."_...
HADLEY, MA 01075 Undersecretary Not valid without signature
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor Specialty ,Iv �,/ -
License: CSSL-098784 , �,
is
1 I ',
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MATTHEW COX '-
r
54 HADLEY STREET'' $4,-, 4 i
SOUTH HADLEY MA `9 I e '' .�
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Commissioner 04/28/2015
MA Construction Supervisor ti 9I7III /MA HIC#148198/CT HIC.556609
Olde Hadleigh Hearth & Home Center, Inc.
119 Willimansett Street, South Hadley, MA 01075 Tel (413) 538-9845, FAX (413) 538-8753
WOOD STOVE INSTALLATION CHECKLIST
Permit
A building permit is required for the installation of any solid fuel burning
appliance. The building permit and installation inspection are limited to the
stove installation and not to the stove construction.
Stove
A) Type/radiant circulating
B) Manufacturer 'test label
4 (after July 1 , 1979 only)
Name/Model No. Collar size
Dimensions/Height Length Width
Chimney .
A) New • Existing
B) Size (flue area)
C) Other appliances attached to flue (Number and flue size)
D) Metal (Manufacturer—name and type) _M
E) Masonry/Lined
Unlined Flue liner
(type 6 manufacturer)
F) Height (refer to diagrams) cap
\\'\
9 Z
1 -•,'\, i e
�( t 1 {fort Cfr,
Li. .2 HEARTH
•
CHIMNEY HEIGHT
Hearth (min. 1 hr. fire resistance) A) Materials
B) Sub-floor construction
. , C) Minimum dimensions (refer to diagram)
Clearances and Wall Protection(.see stove instal lat ion clearances chart)
A) Type of wall protection provided
B) Clearances (refer to diagrams)
. ,
—f<:,,,, ---- --- - n ss
.------i:E]:::/ -- *--'
,,, FIREPLACE CORNER WALL/CENTER
The Commonwealth of Massachusetts I Print Form
Department of Industrial Accidents
Ni{ L Office of Investigations
1 Congress Street, Suite 100
'-vi .. Boston, M4 02114-2017
l 4 ';�. 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.
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. 0 I 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
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 me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. ❑ Building addition
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 11.0 Plumbing repairs or additions
myself. [No workers' com right of exemption per MGL
y t comp.
c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] ' e 13. Other 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 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:Travelers Insurance Home Improvement Contractor's Liscense#148198
Policy # or Self-ins. Lic. #:IEUB5197B81 Expiration Date: 7/12/20/1
/ ni&b/7 ,
Job Site Address: City/State/Zip:4 ', Jiy,7�A// 4-
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date)%4I
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 certik under the rains and penalties of er'u that the information provided above is true and correct.
Signature: _Arida— IDatel8/'10/'201'5'
Phone #;538-9845 CS SL #98784
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 S
* % Massachusetts �.�.�
11' � �
r� D OF BUILDING INSPECTIONS
�,4 '-;:4 AUG M2-12 in reet • Municipal Building ''1 •et°
* ., !
543 ( No thampton, MA 01060
HAMpTON7NSPECt p
MA 0/061.°A18
SINGLE OR TWO FA ' OLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check#
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS � I T— /1/(9/LJ Et'rJ 7+'r i� / 6710
1. Name of Applicant: /��` &J /It�by ( / x C '/ �]_
Address: �C ( 4 I�'iU H 4 AI 5/ Telephone: 7/✓ `c `J ->0 ti
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: iC Owner Contractor
4. Type or Brand of Stove: //' Z Vt 6:5
Contractor's Name: Arnett/ (G'/1. a/de de %4o /kg4 74h97'%
Contractor's Address: /' f/ �►�l Ll Y /4
Contractor's Phone: V/9 5-��J 9i <$_
Construction Supervisor s License Number: 9187-8-Y Expiration Date: f e/.5-
Home Improvement Contractor Registration Number. /.44/ or Expiration Date: 9/`,gi/2
Ali must complete a Workers ompensation Insurance Affidavit 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: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
21 MANHAN ST BP-2014-0188
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 199 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-2014-0188
Project# JS-2014-000318
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.): 10193.04 Owner: HEADY LYN C
Zoning:URB(100)/ Applicant: HEADY LYN C
AT: 21 MANHAN ST
Applicant Address: Phone: Insurance:
21 MANHAN ST (413) 584-7041 () WC
NORTHAMPTONMA01060 ISSUED ON:8/15/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL FPX DVL GSR2 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 8/15/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner