25-062 (3) Freestanding Pellet Installation
Caution: Follow the pipe manufacturer's installation instructions and directions for
passing through combustible walls and ceilings. Check local codes in your area.
Illustration I
- — Our Part AC-3000 is
acceptable for
Must have minimum through-the-wall
3"adapter before tee installation.
for longer run. (AC-3100 for 4000+
For shorter run
ft. installations.)
(such as Masonry
Connection below),
tee alone is - �---�:-- _ — �
t acceptable.alone
,g-m,n- Basement Installation should
be performed by
E 3'clearance professional installer. Use
>3asamat �I 3"metal pipe and coupler
Installation
/ for Outside Combustion Air.
Minimum 3' clearance from
0� ground to the Pellet Vent
- -
'"Out de L/ —
� l.� — -- Exhaust Pipe.
it Hipe
1?utside AIR 1S I{ (ATORY IIII— -
fo WW at W l pIxAy. I
f Li on Masonry Connecti
-T
f U -
1.If 3"flue pipe exceeds 15' in length, increase to 4" flue pipe for remaining flue connections.
2. Total flue length should not exceed 35'.
3. Horizontal run not to exceed 4'.
4. Floor protector must extend 6"from front of unit,4"from sides and 1"from rear.
5.If the total run of outside air connection exceeds 6', if more than 2 elbows are used,or if a
basement install, use 3"metal pipe(and coupler)instead.
6. Outside Air is mandatory}or proper safe operation.
FLOOR AND WALL PROTECTION
Floor Protection
If your floor is constructed of a non-combustible material such as brick or concrete, there is no
need for floor protection. If the floor is constructed of a combustible material such as hardwood,
linoleum, or carpet, then you will be required to use floor protection between the unit and the
combustible. The protection should be U.L. approved or equivalent and must be large enough to
provide a minimum of one inch (1.0") behind, four inches (4.0") on both sides of the stove and at
least six inches (6.0") in the front of the unit. This floor protection is intended as spark and ember
protection only, therefore it need only be noncombustible (there is no required R value).
INSTALL VENT AT CLEARANCES SPECIFIED BY THE VENT MANUFACTURER.
Wall Protection
From the rear and the sides of this stove only six inches (6") of clearance is required to paneling,
wallpaper or drywall. The pellet vent pipe usually requires the standard three inches (3") of
clearance, or as recommended by the manufacturer. Normally additional wall protection is not
required with this type unit.
s
PELLET VUEL,BURNING ROOM HEA R �
'MODEL:25-PDVC/55-SHP10 MIr ELANb STAVE WORKS,
p 0 SOX 206
SERIAL NO. MONROE,VA 2457,4
us MFG.DATE
WIN 022013
TF5TEI97fl: AM E 1509-93:OREGON 814.23.900 THRU INSTALL WITH MINIMUM
814-23-909 AND ULC S627-I 0O UL 1482 CLEARANCES TO WALLS
THIS PELLET FIRED APPLIANCE HAS BEEN TESTED AND LISTED FOR USE AS SHOWN,
IN MANUFACTURED HOMES.
"FOR USEWITH PELLET FUEL' 13"
INPUT RATING:38,000 BTU.__ _ ELECT.RATING:120V.-& HZJA
M KEEP DOOR&HOPPER LID CLOSEDTIGHTLY DURING OPERATION. 6
■UNIT MUST BE PLACED ON A NON-COMBUSTIBLE FLOOR PROTECTOR
EXTENDING OUT6"TOTHE FRONT AND 4"TOTHE SIDE AND 1'TOTHE BACK. r'
K CONTACT LOCAL BUILDING OR FIRE OFFICIALS ABOUT RESTRICTIONS& SI DEWALL-BACKWALI.
INSTALLATION INSPECTION INYOUR AREA. INSTALLATION
■,INSTALL&USE ONLY IN ACCORDANCE WITI4THE MANUFACTURER'S
INSTALLATION AND OPERATION INSTRUCTIONS.
10 CHIMNEY CONNECTORS:3"DIAMETER MIN.PELLETVENT PIPE.INSTALL
` AT LEAST 3"FROMWALL OR CEILING. 6"
•REFERTO LOCAL BUILDING CODE&MANUFACTURER'S INSTRUCTIONS
FOR PASSINGA CHIMNEY OR CONNECTORTHROUGH A COMBUSTIBLE 3,
WALL. s,. •
•MEETS EPA PARTICULATE MATTER REQUIREMENTS FOR WOOD HEATERS
BUILT-AFTER JULY 1,1990.
s • • • CORNER INSTALLATION
t IGHTINGINSTRUCTIONS:PLACE A HANDFOL OF PELLETS IN BURN
POTWITH FIRESTARTER AND IGNITE.CAUTION:TIGHTLY CLOSE°DOOR 1"
AND HOPPER LID.SET HEAT ON MEDIUM ONCE FIRE IS BURNING WELL.
OPERATETHIS UNIT ONLYWITHTHE FUEL HOPPER LID CLOSED.FAILURE 4„ 4„
TODOSO MAY RESULT IN EMISSION OFPRODUCTS OF COMBUSTION
FROMTHE HOPPER TINDER CERTAIN CONDITIONS.MAINTAIN HOPPER
SEAL IN GOOD CONDITION.DO NOT OVER FILLTHE HOPPER.
6„
DONOTTOUCH.HOTWHILE OPERATING. FLOOR PROTECTION
KEEP CHILDREN AND ALL COMBUSTIBLES MIN.SIZE 31"X 32"
AWAY FROM UNIT,
MAY CAUSE SKIN BURN.SEE INSTR.MANUAL.
City of Northampton 212 Main Street, Northampton, MA 01 060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton
k Massachusetts
I { f DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building •J�:• b.
t\ Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and in pections are made
I understand the above.
VI ome owner/resident's signature requesting exemption)
I call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
x 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Infornmation Please Print Legibly
Name (Business/Organizati on/Indivi dual):
Address:
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
employees (full and/or part-time).* have hired the sub-contractors 6. E]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 g. ❑ 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,E] 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#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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:
Policy#or Self-ins.Lie. #: 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 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 $;50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Ines . ations of the DIA for insurance coverage verification.
I o hereby cer ' unde a ns and penalties ofperjury that the information provided above is true and correct.
Si ature: `L / Date:
Phone#:
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#:
SECTION 87 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not 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 . Home Owner.Egempt><on
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.CMR 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-year 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)
ou hire to perform work for you under this permit.
he undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
orthampton Ordinances,State and Lo ngawws and State of Massachusetts General Laws Annotated.
omeowner Signature
I
i
I
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing E7
Or Doors 1]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[Z] Siding [0] Other[0]
Brief Description of Proposed �� Gl� �/� -{ ve
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a;'If Newhouse and_or:add t>ion to`exis#inq housmg, complete the followlnd:
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? 'o! l!G ll Fireplaces or Woodstoves 't Ic" Number of each-
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 900 ft. of wetlands? Yes No. Is construction within 900 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 TOR BUILDING PERMIT
I, 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
1, 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.
Print N
ig ature of Owner/Age t V 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'1
Building Department
Lot Size
Frontage --
Setbacks Front
Side L:' f R: L:l I R:I
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved r 1---
parking)
#of Parking Spaces — I
Fill: �..W y..._�_..,__....�.. -- I, �,...�....,._..�..�..�..._-I€�_ ......._....�...,_.�.,,_...._ F
(volume&Location)
A. Hasa Special Permit/Variance/Finding ever been issued for/on the site?
NO ( DONT KNOW Q YES Q
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW Q YES Q
IF YES: enter Book Pagel t and/or Document#(
B. Does the site contain a brook, body of water or wetlands? NO 0�/ DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , 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
IF YES, describe size, type and location: 1
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�' Department use only ,
Q""'
r - �_ City of Northampton Status,ofPerrnr<, ��
M
Building Department Cdrb CuT/Drirce�+ay Petmtt
NOV — 201 212 Main Street SewerlSepticAvaifabiltty
r.
M. r Room 100 aAA
4
ortham ton MA 01060 Twa Setsot stuctciral Pia�rs' z
DEPT:CF POKL J NG iNSPEC-MN$ p t rz i.
NoR�rArs ro a,n�AO� 3-587-1240 Fax 413-587-1272 Plof%/Site Plans $ ",s'
_.,c._W,;�-,.._ Ins.u,. -.� i. u+` ]IE:�:! ".,s.-"a,,�>,v��-fir„-2':". 'r%'.5-'
Other Speoify'` r ,T -'
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
This section to be completed by office
1.1 Property Address, a s
rl�1r! d Map Lot Urnt
y
r.
ME
District
.d ►VI r
Y V �EIm St-District. _. - CB District ,:..... ..�.
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED:AGENT:'
2.1 Owner of Record:
"ed
Name rint r Current Mailing Addre s: -
st Telephone
gnature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant licant
1. Building (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=0 +2+3+4+5) Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/lnspector'of Buildings: Date
111 OLD FERRY RD BP-2016-0633
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25 -062 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-2016-0633
Project# JS-2016-001054
Est.Cost: $1000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 13677.84 Owner: NIEDZWIECKI PATRICK
Zoning-: Applicant: NIEDZWIECKI PATRICK
AT: 111 OLD FERRY RD
Applicant Address: Phone: Insurance:
111 OLD FERRY RD (413) 478-7153 O
NORTHAMPTONMA01060 ISSUED ON:11 1512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SUMMERS HEAT 55SHP-10 PELLET
STOVE
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 11/5/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner