09-006 (2) NOTE:If this estimate is for a gas unit, the customer is responsible for paying the
Plumber or Gas Company for piping and connection of the gas to the unit.
Or
If this estimate is for a wood unit, the customer is responsible for obtaining a
wood installation or building permit from the local building inspector's office and for
the final safety inspection upon job completion.
Customer should be aware that all Inserts have electric cords.
We propose hereby to furnish material and labor—complete in accordance with
these specifications.
Payable as follows: $200.00 deposit received.
Payment in full is due prior to the day of Installation.
All material is guaranteed to be as specified.All work to be completed in a
workmanlike manner according to standard practices.Any alterations or deviation
from the specifications involving extra cost will be executed only upon written orders,
and will become an extra charge over and above the estimate.All agreements are
contingent upon strike, accidents or delays of which are beyond our control. Owner is
to carry fire, tornado, and other necessary insurance. Our workers are fully covered by
Workmen's Compensation Insurance.
This estimate may be withdrawn by us if not accepted within 30 days.
Customer's signature denotes acceptance of our estimate and that specifications
and conditions are satisfactory and that we are authorized to do the work as specified.
Payment will be made as stated above.
Olde Hadleigh Hearth&Home Center, Inc. Estimate
119 Willimansett St Rte.33
South Hadley, MA 01075 Date Estimate#
413-538-9845 6/21/2013 108990
Name/Address
Jerry Mandel
PO Box 354
Cataumet,MA 02534-0354
Project
Description Qty Rate Total
Jotul Oslo Matte Black 1 2,469.00 2,469.00T
Aircooled 6x24 1 97.92 97.92T
6x25 Liner 1 725.00 725.00T
12x18 Top Plate 1 60.34 60.34T
Damper Sealing Kit 1 40.00 40.00T
Extra Metal for Damper 1 25.00 25.00T
Labor 1 800.00 800.00
Customer Deposit 6/7/13 ck#2303 1 -200.00 -200.00
Top of chimney will have 1 piece of bluestone removed to allow
liner to be installed and recement down after install
Sales Tax Payable-MA 6.25% 213.58
Total $4,230.84
Customer Signature 0 Via
MA Construction Supervisor 9/7,41 /MA HIC#148198/CT HIC.556609
Olde Hadleigh Hearth & Home Center, Inc.
119 Willimansett 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) Type/radiant 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—TM; a;71;-0--------
C) Other appliances attached to flue (Number and flue size)_
D) Metal (Manufacturer—name and type)
E) Masonry/Lined
Unlined Flue liner
(type & manufacturer)
F) Height (refer to diagrams) cap
I „„.,.. /c,'
-f. ro z
I ! ...,...
I{ lftf(7 l.ff)
_.
HEARTH
CHIMNEY HEIGHT
Hearth ( A) Materials
min. 1 l,r, fire resistance)
B) Sub-floor constriction
C) Minimum dimensions (refer to diagram)
Clearances and Wall Protection(
see stove installation clearances chart)
A) Type of wall protection provided _
B) Clearances (refer to diagrams)
•
-T1 Byrn
.4‹
�— . ( — •
o•.
FIREPLACE CORNER WALL/CENTER
•
• ,,-N The Commonwealth of Massachusetts [lint Form
Department of Industrial Accidents
;--.--1_,41-
�1 1 _._3;�fi Office of Investigations
r4. 1 F ' I``1,
.w 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):
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. 0 I am a employer with 8 4. n I am a general contractor and I
employees(full and/or part-time).* have hired the sub contractors 6. ❑ New construction
2.n 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'
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 11.0 Plumbing repairs or additions
myself. [No workers' com right of exemption per MGL
y comp. 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no Install wood stove
employees. [No workers' 13.F4 Other
comp. insurance required.]
Any applicant that checks box#1 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:Travelers Insurance Home Improvement Contractors Liscense#148198
Policy # or Self-ins. Lic. #:IEUB5197B81 Expiration Date: /i / 8/y
Job Site Address: 4/711i(// 4/0/ City/State/Zip: 'if'A 4/9 oa..2--
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
/
Signature: �. Date.
0 //4S2-,
Phone #:538-9845 CS SL #9878
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#:
,
City of Northampton 0.,„ ,i,
2„, ” Massachusetts . .- r,;r
3 = 4 * ',
DEPARTMENT OF BUILDING INSPECTIONS = '
212 Main Street • Municipal Building `.
Northampton, MA 01060
DEPT.O 's 1°� IN0 ECTIONS
NORTHAMPTON,MA 01060
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 # 3�2
`� PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 2/c'l e �/I(9h M.,.2.•27 1-4/xe ( ,ic
Address: /l7 ht///%3'l,/'.St' ✓ . v ' /��/ alp Telephone: T/3 i3? %W5
2. Owner of Property: Gerd lcl /H U.n c. e. I /
Address: T d O kieooecIy Rd., `.eecis Telephone: 7? '- y'9 I`03-3-8
3. Status of Applicant: Owner ✓Contractor
4. Type or Brand of Stove: ,271"L ale x"566
If applicant is not the homeowner:
Construction Supervisor's License Number 1 9 g//�4 p
V Expiration Date , e. /5--/5--Home Improvement Contractor Registration Number /7 f/ r 9 Expiration Date 7 /2 /3
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: I hereby certify that the information contain er•'n is true and accurate to the best
of my knovwle ge./
DATE: 9 /3 APPLICANT'S SIGNATURE ` i
417-DATE: </ /A3 HOMEOWNER'S SIGNATURE /
APPROVED f�
DATE: 7/1 ft 3 BUILDING OFFICIAL —L v �!
f.
400 KENNEDY RD BP-2014-0045
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 09-006 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-2014-0045
Project# JS-2014-000114
Est. Cost: $4230.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sq. ft.): Owner: MANDEL GERALD&JOHN LATAWIEC
Zoning:RR(100)/WSP(100)/ Applicant: OLD HADLEIGH HEARTH & HOME CENTER
AT: 400 KENNEDY RD
Applicant Address: Phone: Insurance:
119 WILLIMANSETT ST (413) 538-9845 WC
SOUTH HADLEYMA01075 ISSUED ON:7/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL JOTUL OSLO F500
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 7/18/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner