43-043 (4) Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 148198
Type: Private Corporation
Expiration: 9/13/2015 Tr# 243956
OLDE HADLEIGH HEARTH & HOME CENT
MATTHEW COX
119 WILLIMANSETT STRETT RT 33
S. HADLEY, MA 01075
Update Address and return card.Mark reason for change.
j_i Address ❑ Renewal Employment L, Lost Card
3CA 1 t5 20M-05/11
�a, �J�G'�07117110I1to(CY(��4j U�(C(J92c�ct�G't(+i
OMee of Consumer Affairs&Business Regulation License or registration valid for individul use only
�1 ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
e istration: Type:
Office of Consumer Affairs and Business Regulation
9 148198 yp
j xpiration: 9/13/2015 Private Corporatior 10 Park Plaza-Suite 5170
?� Boston,MA 02116
)LDE HADLEIGH HEARTH&HOME CENTER, INC.
MATTHEW COX
119 WILLIMANSETT STRETT RT 3
i. HADLEY, MA 01075 Undersecretary Not valid without signature
Massachusetts r Department of Public Saf(-: i.y
Board of Building Regulations and Standards;
"()11sti-liction Supervisor spechilty
1—iCense . CSSL-0,9'8784 F ,,
�t
MATTHEW COX, ` ��
54 HADLEY STREET'), j ),
SOUTH HADLEY MAY7 ..�I ,.► ts , .�
r
04/28!2015
C o rnm i s s i o n e r
MA Construction Supervisor h 9Y7,? /MA HIC#148198/CT HIC.556609
Older Hadleigh Hearth & Home Center, Inc.
119 Willimansett Street, Sopth 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.
S tove
A) TY1ic/radiant circulating -_
B) Manufacturer 'test label
after July 1 , 1979 only)
Name/Model No. Collar size _
Dimensions/Height Length Width—_ _
Chimney
A) New Existing
e) Size flue area
C) Other appliances attached to flue Number and flue size) —
0) Metal (Manufacturer—name and type)
E) Masonry/Lined
Unlined Flue liner
type L mnnufacturerj
F) Heiqht (refer to diagrams) cap
\ I I �I'',.
7 ...,...
_�_,•fi—•.--+•�' •\� ems' z \
j rz
♦ft.(T Ii•�
HEARTH
CHIMNEYIHEIGHT
Hearth (min. I fir. fire resistance) A) Materials
B) Sub-floor cons.trnction
C) Minimum dimensions (refer to dlagram
Clearances -and Wal l Protection(see stove instal rat ion clearances chart)
A) Tyre of wall protection,.provided
B) Clearances (refer to diagrams)
,., rIREPLACE CORNER WALUCENTER
i ne uommonweattu of Massachusetts rr im rorm
Department of Industrial Accidents
Office of Investigations
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 Leizibly
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 , ❑✓ I am a employer with 8 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ 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 10.0 Electrical repairs or additions
3. [7 I am a homeowner doing all work officers have exercised their 1 l.❑ 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 Install wood stove
employees. [No workers' 13.E Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I tomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
i fo rmation.
isurance Company Name:Travelers Insurance Home Improvement Contractor's Liscense#148198
olley # or Self-ins. Lic. #:IEUB5197B81 Expiration Date: 7/12/20141
)b Site Address: 6,W,0 Ar• City/State/Zip:
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
do hereby eerti under the pains and enalties o er u that the in ormation provided above is true and correct.
Tnature: Date 8/10/201
lone #:538-9845 CS SL#9878
Of 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#:
of Northampton
i
Massachusetts
MAY 192014
k DEPAR� OF BUILDING INSPECTIONS
L-- yam,
Electric. PIL7L g�r G
4ono reet • Municipal Building}., �
l�-!.�J'OGO Nor h ton, MA 01060jY ' s
Nc•tha�Y'ptor:. �P
SINGL OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FR WOOD PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check # dH
PLEASE TYPE OR PRINT ALL INFORMATION
Name of Applicant: �" rr'1r
Address: 4 A Irl''t ( )Jr. F1 0 Vf,VI CC, Telephone:4 13
2. Owner rtY
ofProP e dame, '} �3 °�fC7 " � `.►� ��
Address: Telephone:
3. Status of Applicant:Zowner Contractor
4. Type or Brand of Stove: zL �� 767) -Awe
If applicant is not the homeowner:
Construction Supervisor's License Number o G- Expiration Date /S
Home Improvement Contractor Registration Number / 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 conta' here' is a nd accurate to the best
of my kno7/;7/-,/
DATE: APPLICANT'S SIGNATU
DATE: f~ HOMEOWNER'S SIGNATURE r
APPROVED
DATE: BUILDING OFFICIAL
46 AUTUMN DR BP-2014-1217
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43 -043 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-2014-1217
Project# JS-2014-002059
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.): 10149.48 Owner: BUTLER GERRIANN
Zoning: Applicant: BUTLER GERRIANN
AT. 46 AUTUMN DR
Applicant Address: Phone: Insurance:
46 AUTUMN DR (413) 584-5549 O WC
FLORENCEMA01062 ISSUED ON.512012014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL AVALON-SPOKANE 1750
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 5/20/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner