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35-210 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 •`Z circulating ., B) Manufacturer '")04 j test label after July 1 , 1979 only) Name/Model No. osIU f7 500 Collar size' Dimensions/Heightt'/z Length 1e Width—_ Chimney A) New Existing B) Size (flue area) C) Other appliances attached to flue Number and flue size) 0 D) Metal (Manufacturer—name and type) E) Mason ry/Lined Unlined Flue liner } e, 't }� S�,G� L� 1 type & manufacturer F) Height (refer to diagrams) cap _�_ _ 4c[ff! 7•�•) f HEARTH CHIMNEY HEIGHT Hearth(min. 1 hr. fire resistance) A) Materials tr ) ' 1� i) 1, }(e��r�h e "fi B) Sub-floor construction (L L Aj c je- C) Minimum dimensions (refer to diagram Clearances and Wal ! Proteetion(see stove installation clearances chart) A) Type of wall protection provided C tt ;g\L( �wsl�(� w;1h � 1(v S1%•e( V B) Clearances (refer to diagrams) k7 --- -- FIREPLACE CORNER WALL/CENTER . The Commonwealth of Massachusetts Department of Industrial Accidents Office of In vestigation 600 Washington Street Boston,Mass.02111 Worker's Com ensation Insurance affidavit Name: Address: City: Telephone#: • • I am a homeowner performing all work myself. • • I am a sole proprietor and have no one working in any capacity. I am an employer providing workers'compensation f r my.emplpyees working on this job. Company Name: 0 Onitr Address: City: a&11 k Telephone#: Insurance Co. Policy#: CIE • d am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who the following workers'compensation policies. Company Name: Address: City: Telephone#: Insurance Co. Policy#: Company Name: Address: City: Telephone#: Insurance Co. Policy#: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forward to the Office of Investigation of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Print Name: Allan �• �� ����� L , Phone# 415,506ir Official use only- o not write this ar o e y City or Town Official City or Town Permit/License#: • -Building Permit Department • -Licensing Board • -Check if immediate espouse'a�equ' d • -'Selectmen's Office • +iealth Department Contact person. �_ hone#: 3 • •Other N ij ..:1 1:.11 1 r f a rl /71 IS E uEding IMA 11�71-Y)WT E iTTIO-NAr,. , , -.EDC-E-NMNT Wyl -E 0 VY;iER 17XE� ,ws -e home vvr -,.LL A, The Stazc-olf-Maszach,�set-ts allo- Lli 10 ,e,,Le rich under 780C--,, fR 108.14 to " az, " !il ,-�cr. Tll'.-,� sia-Le defEnes "Hom.t�- er el'soll(s) -- SuD�., " � act n;-VV 71 who owns aparcel on be, a one qr two fami�; atzac-,,e.-4 or stiuzc:L-,res accessoiy to such use and-✓or fa=-. Struct-L-'res. person who con sI acts,- nore this one home m a-L,�ic-year per-,od shall not be considered a home ovm-er.- ,Fhe btul d der,-aE7,.Mez,--for the civ� an-yPerson(s)who seek to L,S--the home C-7-,zer ex=.Mptiol:, tO act as that by doLa!z so you become responsible for compliance with state building codes and reTula-Ecns. The inspect tion Process requires that the building department be called A to Llspec-t wort at various stagges. which include-foundation/fOotinsrs (before backfAl ). 549-notabe holes (before i)our). a rough building:ins-pection-(before work is c".ce:ged). i--wilation inszectiarl (if reguired) agAA Finn! buildin-gi=er-tion. The bu-ilding department requires these ias-oections before the work is concealed, failure to secure these. insuections can result in failure to obtain a ce-tificate of OCCUDancl um-61--the-work-tag--be inspected- U'the ho=eo-,aer=' * es other trades to perform 'Work(-ectriczzl plumbing L- gas) the homeaw-ner 7-iUl be res-Dorsible to E--,aKe score that t, ir I .-e trades hired secure the proper- F-e=ts in C,-LJL--=On to the building permit issued, and that they get their required inspections. ol'Lt lndl7ilduall trades to se-c-,.re the permits and in:5pe--tions as• req=e-l-- can D-E-LAY tie pro iect L,-r III such time as the proper permits ant--, inspect.,or's are made understand the above. (dome owner/residents sian- ature requesting eiemption) I will, call to schedule all required building inspectors necessary for the buildizig, pe,-j-fT, issued, to me. Matz Address-of locat, ion Department of Industrial Accidents Office of In vestig ations �} 600 Washin-ton Street Boston, lVA 02111 _ www.naass.l ov/dirt Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print f,eaiblti Name (Business;Or-anizati(Dn/Individual): A A A City/State/'Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑] New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building,addition [ 'o workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 1().F Electrical repairs or additions �.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per NIGL 12.7 Roof repairs insurance required.] _ c. 152, §1(4), and we have no employees. [NN workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box ml must also fill out the section below showing their workers'compensation policy information. 'Ho'Ho meoavners wiro submit this affidavit indicating thev are doing all work and then hire outside contractors must submit a new affidavit indicating such. Ce m actors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Naive: _ Polic,a=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 Z5A of TIGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lnvestigatiorns of the DIA for insurance coverage verification. I do lzereby cerzify-zzrade,tlie-pains anttpetta-lties-ofperjz�y tizat-the information provided above is true and correct. /anature: Date: Phone = _ ___,�k__r�ficirzLz�se_on1�.�_D_o_zzot�vrite�n�fzis_area,_t�be_eompleted�_.city_or town_of�ca� Citv or Town: Permitrlicense# Issuin, Authority (circle one): 1. Board of Health 2. Building Department 3. C:-v/T own Clerl� !.. Electrical Inspector 5. Plumulng Inspector i� o. Outer Phone i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Nut Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§-25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ 11. - Horne Owner Exempti©n The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CNIR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-vear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition F-1 Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[p] Other[o] ee De scriptior},oi:P,rppQ h a r v 01 ] 0�0 14 ��/j V� V-D V r" : 11' �l 1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a--OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I; as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. /111, t Na 1 2 eo � Sign ur f Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved -- -- ............ oarkine) #of Parking Spaces Fill: No une&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use.only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot(Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 96 S g4l&4..� ��a.� Map Lot Unit O �-� ,w� AJA 0 1 0 Z Zone Overlay District C/v` ( Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ta wt a° S 6t y 3 q►n A / FY'c d C V5 908 a�.� /Qe( '(710 9441 al Name rint) 1 Current Mailing Address: Telephone ig ture 4V r 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS I m Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �[ � 0 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 5a Check Number S�' This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building,Commissioner/InspectorofBuTdFngs --_ Date BP-2008-0668 GIS#: COMMONWEALTH OF MASSACHUSETTS 4 ` " ` ` ' i ! CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: BUILDING PERMIT Permit# BP-2008-0668 Project# JS-2008-001023 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 43995.60 Owner: GUGGINA JAMES &FRED E CRISP Zoning: SR Applicant: GUGGINA JAMES & FRED E CRISP AT. 908 RYAN RD Applicant Address: Phone: Insurance: 908 RYAN RD (413) 587-9410 O FLORENCEMA01062 ISSUED ON:112812008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 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 1/28/2008 0:00:00 $25.00318 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo