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28-029 Olde Hadleigh Hearth & Home Center, Inc. Estimate 119 Willimansett St Rte.33 South Hadley, MA 01075 Date Estimate # 413 -538 -9845 ` 10/17/2011 107083 Name / Address Stacia Potter 685 Ryan Road Florence, MA 01060 Project Description Qty Rate Total Jotul F3CB Black 1 1,692.00 1,692.00T Short Legs 1 69.00 69.00T 6 Tee 1 80.50 80.50T Tee Cover 1 30.80 30.80T Flexible Liner Section 1 100.00 100.00T 6x48 Chimney Liner 3 87.95 263.85T Flex to Rigid Adapter 1 18.20 18.20T Damper Sealing Kit 1 40.00 40.00T Top Support Kit 1 77.15 77.15T 6 Rain Cap 1 57.70 57.70T Mantel Shield 1 75.00 75.00T Labor 1 650.00 650.00 Customer Deposit 10/15/11 1 - 200.00 - 200.00 Sales Tax Payable -MA 6.25% 156.51 Total $3,110.71 Customer Signature it NOV -16 -2011 09:43A FROM:METRAS INS AGENCY 4135328522 TO:5388753 P.2 ACORD CERTIFICATE OF LIABILITY INSURANCE PATE Y PRODUCER (413) 536 -1491 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Metras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 2030 Memorial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chicopee MA 01020- INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A Travelers Olde Hadleigh Hearth & Home Center ,Inc. INSURER B: 119 Willimansett St. INSURER C: INSURER D: South Hadley MA 01075- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCL SIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AMYL POLICY EFFECTIVE POLICY EXpIRATIOPT LTR ,INSRO TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY) DATE {MIDDAY) LIMITS A GENERAL LIABILITY 16607910A718 08/30/2011 08/30/2012 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 , 000 PREMISES (Ea occurrence) 5 I CLAIMS MADE © OCCUR / / / / MED EXP (Any one person) s 5 , 000 PERSONALS. ADVINJURY $ 1,000,000 / / / / GENERAL AGGREGATE $ 2,000,000 "' G�EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG S 2,000,000 l POLICY I I JECT ri_LOC / / / / A AUTOMOBILE LIABILITY HA2055C669 11 /01/2011 11/01/2012 COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO (Es accident) _ ALL OWNED AUTOS / / / / BODILY INJURY T S X SCHEDULED AUTOS (Per person) HIRED AUTOS / / / / BODILY INJURY S NON -OWNED AUTOS (Per accident) / / / / PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ I ANYAUTO / / / / OTHER THAN EA ACC S AUTO ONLY: AGG 5 A EXCESSIUMBRELLA LIABILITY 2649Y614 08/30/2011 08/30/2012 EACH OCCURRENCE S 5,000,000 OCCUR 0 CLAIMS MADE AGGREGATE S 5,000,000 S R DEDUCTIBLE / / / / S RETENTION $ 10,000 _ S A WORKERS COMPENSATION AND IEU851978B1 07/12/2011 /2013 It�MIIsI i ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S 100,000 OFFICER/MEMBER EXCLUDED? / / / / E,L.DISEASE - EAEMPLOYEES 100,000 U yes, describe under ---., SPECIAL PROVISIONS belo E DISEASE - POLICY LIMIT S 500,000 OTHER r / / / / / / / / / / / / DESCRIPTION OF OPERATIONS ILOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) - ( ) - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Stacia Potter FAILURE TO DO 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 685 Ryan Road INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE $ruc ei . p 9.. , .,- Florence MA 01062 - T �Gf�i�G ACORD 25 (2001108) m ACORD CORPORATION 1988 INS025 poops PeOa ot2 MA Construction Supervisor #CS009989 / MA HIC #148198 / CT HIC.556609 Olde Hadleigh • Hearth & Home Center, Inc. 119 Wiliimansett Street, South Hadley, MA 01075 Tel (413) 538-9845, FAX (413) 538 -8753 WOOD STOVE INSTALLATION CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and'not to the stove construction, Stove A) Typc /r circulating _ B) Manufacturer 'test label ,, (after July 1, 1979 only) Name /Model No. Collar size Dimensions /Height Length Width Chimney A) New " Existing B) Size (flue area) C) Other appliances attached to flue ( Number and flue size)_ 0) Metal (Manufacturer —name and type) E) Masonry /Lined Unlined Flue liner (type L manufacturer) r) Height (refer to diagrams) cap \ I o.. Io• ` IL ..,.... L A 64) 4 IIEARTH CHIMNEY HEIGHT Hearth (min. 1 hr, fire resistance) A) Materials B) Sub-floor consArt$ction . C) Minimum dimensions (refer to diagram) Clearances .and Wall Protection( see stove installation clearances chart) A) Type of wall protection..provided 8) Clearances (refer to diagrams) • == - 1-7 . • -4.4< 4 1 ... rIREPLACE CORNER WALL /CENTER : • The Commonwealth of Massachusetts [ Print Form 1 Department of Industrial Accidents 1 ti t ‹ , E # Office of Investigations �` 1 Congress Street, Suite 100 HIT i,; ' ' Boston, MA 02114 -2017 `' s F www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Olde Hadleigh Hearth & Home Center, Inc. Name ( Business /Organization/Individual): , ... 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 _ * have hired the sub - contractors 6. ❑ New construction employees (full and/or part- time). 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.t 9. ❑ Building addition _ required.] 5. ❑ We are a corporation and its 10.0 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' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no Install Wood Stove employees. [No workers' 13. Other_ comp. insurance required.] * A nd applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 1 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' cornp. 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 License # 148198 Policy # or Self -ins. Lic. #:IEUB Expiration Date: lob Site Address: 6 ? Ol � y /i1 £c/ City/State /Zip: /OlP /7�t�, / / �� � 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 tine 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 certify under the Pains and penalties of perjury that the information provided above is true and correct. Signature:. _ . . = - - -- - . : _ Date: 1. 4 l[ -1 ; . 3 ; ? G >/% .. __ t Phone # : 413- 538 -9845 �, / eek,5 - S Sz y 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 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : L I> 1 - - A D 1.E 1414 n U A I L - r ' t 1 r fr A e 6S " rcrt— t c - ' License Number 11 W l L-i 'AM N c- ST. 1 LfSr 9 8 Address Expiration Date \A43.4)\-.1 OvYIS , S•%. S q/131 9igoa Telephone '7 9. Registered Home Improvement Contractor: Not Appli ❑ Company Name o N ber 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 Exemption 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) 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 ❑ Replacement Windows Alteration(s) J Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks [CI] Siding [D] Other [0] Brief Description of Proposed - Work: NS r'i r iyTrn,.l or Wtk),> ZTO E Te 1. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes X 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 , 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 , as Owner /Authorized Agent hby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and be Signed under the pains and penalties of perjury. Print Name Signature of 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 a (v 1 6.7 s ?. C ■6‘ C Frontage 1 1 �` L S Setbacks Front Side L: R: L: Rear Building Height Bldg. Square Footage � a 9ys F Open Space Footage +t (Lot area minus bldg & paved .2 , Y.5 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and /or Document # • B. Does the site contain a brook, body of water or wetlands? NO ; DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 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 O NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only RECEIVED City of Northampton Status of Permit: � Building Department Curb Cut/Driveway Permit NOV ? 3 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability EcTioNs c MAO °� • • e 41 - 587 -1240 Max A 01060 Two 87 - 1272 Plot/Site Plan Structural Plans DEPT. 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 (D85 R / i rJ R VA I) Map Lot Unit T i'JCC M A b 10(0 - Z Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: <Ak(e - ins (13S 6 Name % Print) _ A Current Mailing Address: ` 14 727 arm 3 Telephone Sig6eture 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 1. Building 2 J j / 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) q 3 0 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 685 RYAN RD BP- 2012 -0511 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 28 - 029 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- 2012 -0511 Project # JS- 2012- 000858 Est. Cost: $3110.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784 Lot Size(sq. ft.): 26658.72 Owner: HEWES JAKETON & STACIA POTTER Zoning: SR(100) //WSP II Applicant: HEWES JAKETON & STACIA POTTER AT: 685 RYAN RD Applicant Address: Phone: Insurance: 685 RYAN RD (413) 727 -8636 0 WC FLOREN CEMA01062 ISSUED ON:11/29/2011 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 11/29/2011 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner