29-307 (9) The Commonwealth of Massachusetts Print Form
- Department of Industrial Accidents
=- Office of Investigations
k I Congress Street, Suite 100
— Boston,MA 02114-2017
www.mass gov/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.El 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.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box BI 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,-.
Job Site Address: G?nnr re,6roojc City/State/Zip: r/ore rice Al 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$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 an penalties o perjury that the information provided above is true and correct.
Signature- Date /S
Phone#: y/,� 6'(/S �?//
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#:
Floor Protector Combustion Air
The stove maybe installed on a combustible floor provided Intake or combustion air can be supplied to the stove
noncombustible ember protection is used. in one of two ways. Consult your local building code or
This protection must extend as follows: CAN/CSA-B365,Installation Code for Solid-Fuel-Burning
Appliances and Equipment before proceeding.
In Canada: 18" (457 mm) on the firing side and 8" (203 1. Outside air supply - (Necessary for mobile home
mm) to the other sides. See Figure#3, below. installation,optional for residential installation.)Out-
side air may be drawn from either underneath the
FIG.#3 Canada Onl y Non-combus-
stove or from behind.
tible To draw outside air through the floor, leave the 4"
Minimum Width-40' knockout or cover late in lace in the rear of the
Minimum Overall Depth-501/2" / pedestal or leg kit ash box enclosure.
Pedestal Model: Cut or drill a 4"diameter hole in the
:18" [203mm] floor anywhere inside the perimeter of the pedestal.
Cover the hole with a 4" x 4" (100 mm x 100 mm)
rodent screen and staple/nail in place.
E Leg Model: Cut or drill a 4" diameter hole directly
O co below the bottom hole of the ash box enclosure. Con-
C) enclosure to the floor with a short 4" diameter
pipe.If you wish to connect the outside air to the rear
°0 hole on the ash box,then remove the 4" knockout or
cover plate at the rear of the ash box.
00 This hole must get its air from a ventilated crawl
N space or be extended with duct to the outdoors(see
W
Figure#3, Page 7). The use of outside combustion
18" [457mm] air for residential installation requires the unit to be
3 secured to the structure to prevent dislodging of the
air duct.
To draw outside air from behind the stove,an outside
In USA: 16"(406 mm)to the front and 8"(203 mm)to the air adaptor may be required (see Optional Blower
sides of the fuel loading door opening. See Figure #4, section). Cut or drill a 4" hole through a wall behind
below.This protection is also required underthe chimney the unit. Use an appropriate household 4" inlet.You
connector and 2" (51 mm) beyond each side. must remove the rear cover plate from the pedestal
or move the cover plate at the rear of the leg kit ash
box enclosure to cover the bottom hole.
FIG.#4 U.S.A. Only
Note: This unit is not designed to be operated with the
Minimum Width-34" firing door open.In addition to the obvious hazard of
Minimum Overall Depth-40 1/2" sparks landing on combustibles, an open fire door
will cause the heater to draw air from the living space
Non-combustible and possibly cause suffocation.
floor protector
2. Room air supply-Remove the cover plate from the
rear of the pedestal or leg kit ash box enclosure. The
stove will now draw its air from the room through this
opening and into the firebox intake.
N
3 Note: The living space around the heater must be well
ventilated with good air circulation.Anything that may
_ - cause a negative pressure can cause gases or fumes
E to be pulled into the living area. During extremely cold
o weather, and especially when burning at very slow
16"[406mm] N rates, the upper parts of the exposed chimney may
0o ice up, partially blocking the flue gases. If blockage
occurs, flue gases may enter living space.
10 SUPER-S D 1 P NERGY ACIFIC 300913-24
E
Super 27 - Pedestal Model Spectrum
28" 27 1/2"
24" 23 5/8" 23 7/8" 23 5/8"
40 L
29 1/81, 29 1/8"
27 5/8" 28 3/8"
'E
,77 r__ A 'I r I
Super 27 - Leg Model Spectrum Classic
28" 27112"
-24" I 23 5/8" 23 7/8" 23518"
29" 29"
28 1/4"
Assembly - Super 27 only -
2 S lace with 1" x 1/2" bolts re-
Crate Removal ) moved.ecure in place y
1) Carefully remove wood top and supports. 3) Carefully place the unit in the upright position.
2) Remove plastic cover.
3) Using a 7/16" wrench, remove lag bolts that secure Leg Kit
stove body to bottom pallet.
4) Place stove body carefully on its back. 1) With the unit on its back,align the ash drawer enclo-
5) Using two 3/4" wrench, remove 1" x 1/2" bolts and sure mounting holes(removable coverfacing up)with
save for later use. the holes on the stove.
6) Remove pallet retaining brackets from stove bottom. 2) Position the legs over top of the same holes on the
stove.
Optional Ash Cleanout System -(Install 2) Secure in place with 1" x 1/2" bolts previously re-
first) moved.
1) With stove body laying on its back, remove the ash 3) Carefully place the unit in the upright position.
system hole coverand gasket located underthe stove.
Discard cover plate and gasket p ,�
2) Inside the stove,remove the two bolts forthe ash dump
from the firebox bottom and insert into the brick retainer !
with the flanges on the the brick retainer pointed away
from the threads on the bolts. e
3) Replace bolts with brick retainer in the firebox
bottom.
4) Place new gasket provided over existing bolts.
5) Install ash dump system over gasket and secure with
two nuts previously removed.
Pedestal Kits
1) With the unit on its back and the removable cover ; {
facing up, align the pedestal mounting holes with the .4
holes on the stove.\ "'
6 SUPER SD1 PACIFIC
ENERGY 300913-24
of Northampton
Massachusetts
1 2 0
Dffe�b7 OF BUILDING INSPECTIONS
E _ 211? Ma;n Street • Municipal Building
Northampton, MA 01060 sst~jy N �1ac
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# d 33V
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:__n4 a rd s-/o 1 _
Address:_q- Ki Vef /S-)' �rr A fi r W ffr'1 Telephone: //.S el SHIP �31/
�J
2. Owner of Property: /M /-a 4 ec
3 FP- �e
Address: de rC�r-aok I✓r. f7/0!'PRe-e— Telephone: -1'
3. Status of Applicant: Owner lzcontractor
4. Type or Brand of Stove: 7C 7Wc r- 27— LJAU'l) u!Z 7 U 1 -Kc Jcx 1 b-e S f V 3
b�senrrt�-
If applicant is not the homeowner:
Construction Supervisor's License Number `�� / Expiration Date
Home Improvement Contractor Registration Number /� �-'!5 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 knowled e.
DATE: APPLICANT'S SIGNATURE
DATE: .3 ° ! _ HOMEOWNER'S SIGNATURE_
APPROVED
DATE: BUILDING OFFICIAL
382 ACREBROOK DR BP-2014-0967
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 29-307 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
CatejZory: woodstove BUILDING PERMIT
Permit# BP-2014-0967
Project# JS-2014-001681
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 44300.52 Owner: NATALE JAMES F JR&CLAUDIA J
zoning: Applicant: BERNARDSTON FARMERS SUPPLY
AT. 382 ACREBROOK DR
Applicant Address: Phone: Insurance:
43 RIVER ST (413) 648-9311 () WC
BERNARDSTONMA01337 ISSUED ON:312112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PE SUPER 27 WOOD STOVE
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