31A-131 The Commonwealth of Massachusetts Print Form
^ Department of Industrial Accidents
_, Office of Investigations
-iµ- 1 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.FSJ 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. 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. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for in any capacity. employees and have workers'
g y p 9. n Building addition
[No workers'comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.1-1 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
employees. [No workers' 13.111 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I.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 Date:7-1-13
•
Job Site Address: 55- ratz5 t3 City/State/Zip:Mr:17 d.rn r>'Itl r i A
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 ilie airs d penalties of perjury that the information provided above is true and correct.
Signature: Date: `S ./ I
Phone#: �r� ! V'I '?-2//
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#:
Installation Fig.#2 Full Flue Liner
Your Insert is designed to be installed into a masonry or fac- ICI
tory built zero-clearance fireplace. The masonry fireplace Rain Cap
must be built according to the requirements of the Standard ■
mil
of Chimneys, Fireplaces, Vents and Solid Fuel Burning ap-
pliances,N.F.P.A.211 (Latest Edition)or applicable National,
Provincial,State or local codes.The installation shall conform •to CAN/CSA-B365, Installation Code for Solid-Fuel-Burning Appliances and Equipment. The factory built zero-clearance fireplace and its chimney must be listed per UL 127 or ULC l-I ril
S610 standards. Stainless Steel
Warning: Under no circumstances isthisheatertobeinstalled Rigid or Flex Liner ,,
in a makeshift or"temporary" manner.
DO NOT CONNECT THIS UNIT TO A CHIMNEY FLUE „FT
SERVICING ANOTHER APPLIANCE.
Fireplace Specifications Mantel or
m EN NI
Top Facing
Your fireplace is required to have the following minimum ■ i = i
iii
sizes: i ./
.■ •
•1 W. mi
WIDTH (at front) 28" (711 mm) ii1M/
WIDTH (at rear) 26" (660 mm) memi■ $
M
HEIGHT 23-1/8" (587 mm) ill �� L`
=ti
DEPTH 18" (457 mm) !' •IN Ii■
_ t■cJ-
Chimney height 15' (minimum). = �Z
A metal tag is provided and is to be fastened to the back al-
wall of the fireplace, if the fireplace has been modified --
to accommodate the insert. C
--
Into a Masonry Fireplace —� :-
Inspect your fireplace for cracks,loose mortar or other physi-
cal defects. If repairs are required,they should be completed
before installing your insert.
The fireplace chimney must be suitable for wood burning use.
Check for creosote build up or other obstructions,especially if
it has not been in use for some time.Have chimney swept.
The existing fireplace damper is to be locked open or removed
completely.
Positive Flue Connection(In U.S.A. only): where a throat
WARNING: Do not remove bricks or mortar from your blocker plate and a short connector pipe is used.
existing fireplace. Note: A clean-out door may be required under local codes,
when a positive flue connection is used. Consult local
Exception: Masonry or steel, including the damper plate, codes.
may be removed from the smoke shelf and adjacent damper
frame if necessary to accommodate a chimney liner,provided Pacific Energy highly recommends the use of a full
that their removal will not weaken the structure of the fireplace liner as the safest installation and providing optimum
and chimney, and will not reduce protection for combustible performance. When connected to a full liner,the Insert
materials to less than that required by the National Building is able to draft correctly and will prevent problems such
Code. as difficult start-ups and smoking out the door.
The Insert must be installed in accordance with local and or
national building codes. The two methods of flue connection
that are acceptable in most areas are:
Full Flue Liner:(Fig.2,Required in Canada)where a stainless
steel rigid or flexible liner extends from the Insert flue collar
to the top of the chimney.
SINB.BODY 011113-24 PACIFIC 7
ENERGY
Safety Clearances
Please read this entire manual before installation Masonry or Factory Built Fireplace
and use of this wood burning insert.Failure to follow The minimum required clearances to surrounding combus-
these instructions could result in property damage, tible materials when installed into a masonry or factory built
bodily injury or even death.
fireplace are listed below and in figure#1.
We strongly recommend that smoke detectors be installed.
If smoke detectors have been previously installed, you may Minimum Clearances to Combustibles
notice that they are operating more frequently.This may be
due to curing of stove paint or fumes caused by accidentally (Measured From Insert Body)
leaving the fire door open. Do not disconnect the detectors.
If necessary, relocate them to reduce their sensitivity. Adjacent Sidewall 8 in. (203 mm.)
Mantel 26 in. (660 mm.)
SAFETY NOTICE:If this stove is not properly installed,a 12" Mantel with Shield 20 in. (508 mm.)
house fire may result. For your safety,follow the instal-
lation (with part directions. Consult local building or fire officials ( p SINB.MSMBKA)
about restrictions and installation inspection require- Top Facing 26 in. (660 mm.)
ments in your area. with Mantel Shield 20 in. (508mm)
(with part#SINB.MSMBKA)
Side Facing (1.5 in.extension) 8 in. (203 mm.)
NATIONAL We recommend that our products be
FIREPLACE installed and serviced by professionals
INSTITUTE y p
NFI who are certified in the U.S.by the
6
National Fireplace Institute (NFI)
or in Canada by Wood 0 CAUTION: Unit hot while in operation. Parts of the appli-
ance,especially the external surfaces,will be hot to touch
CERTIFIED Training(WETT) Technical Training when in operation. Keep children,clothing and furniture
www.nficertified.org MYYYYMen'"``a away.Contact may cause skin burns.
Fig.# 1
Mantel or Top Facing
_L__ I I I I I I I I
I I I I I I
I I I I I I I I ) 1 .
I 1, I I _ I f26" I I ,I � I
1l I Ii _ i I �o l
AOGent I I '-7 I -/ H H `` I L __L_ 47
- 8" 1 it I
I I �� 1 21"
I I oI I
/ Fireplace '16.,
8.. Hearth
1
3"
SINB.BODY 011113-24 PACIFIC 3
ENERGY
. RECD°,\'
•
�' `� City •f Northampton
1N7M
t5.,--- y I m 0 _0'3 ssachusetts �5�5 • S��f�
�2� r ...-/54.' OF BUILDING INSPECTIONS h
a y � pEPNO THAMPTON,titi y Street • Municipal Building ti.4 `, r
Northampton, Ma 01060 .11. .'-
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#2.21127____
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant )cv7/aS 'Abbe-Q---
Address: 75 /71i9 2I'S ,57 6R/91'8y Telephone: V/� 773 - cf- /
2. Owner of Property: CA_/AA.i fl /?7C.A'1 nor/1
Address: -S. �(� j,ej3 tS 4 re Telephone:
3. Status of Applicant Vll1►'Owner Contractor
4. Type or Brand of Stove: Gig.C r-PC J Jelt6s( \i in m r (,1 a a-1 i iJse t / (UC/y ga
If applicant is not the homeowner. �/
Construction Supervisors License Number 9 9510/ Expiration Date /'6 -1 T
Home Improvement Contractor Registration Number /6 4r 5d Expiration Date 7-c27- /V
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 knowledge.
DATE: ?'‘,/ -7_3 APPLICANT'S SIGNATURE //G%L�
DATE: 24 I / HOMEOWNER'S SIGNATURE I 1! '�j UY 1. ' 1
APPROVED
DATE: BUILDING OFFICIAL
55 FORBES AVE BP-2013-1054
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 131 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-2013-1054
Project# JS-2013-001745
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq.ft.): 12588.84 Owner: KLATZ DANIEL L&CAITLIN E
Zoning:URB(100)/ Applicant: BERNARDSTON FARMERS SUPPLY
AT: 55 FORBES AVE
Applicant Address: Phone: Insurance:
43 RIVER ST (413) 648-9311 () WC
BERNARDSTONMA01337 ISSUED ON:5/6/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL PACIFIC ENERGY SUMMIT WOOD
INSERT 9UL1482)
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 5/6/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner