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15B-011 (3) Insert with Positive Connection REQUIRED IN CANADA. -/J --- iF FJ Fg H Y - w YF iS 1 YY _ - . Yx Insert with Direct Connection (Masonry Fireplace) I NOT ALLOWED IN ' -- CANADA. A block-off plate or 1 other non-combustible -- sealing device (e.g. - - damper adapter) is required. It must seal - the chimney to insure smoke does not enter .� the home while providing the chimney system with sufficient FF . draft. d YY f = © Travis Industries 100-01233 4141211 Fir6plioe-- • . • - . • Insert Placement Requirements • The insert must be placed so that no combustibles are within, or can swing within (e.g. drapes, doors), 36" (915)of the front of the insert (Figure 3 "q"). • Insert and hearth must be installed on a level, secure floor • The minimum clearances, facing, and hearth requirements in Figure 3 must be met. Follow the clearances for the type of fireplace being used—(masonry or zero-clearance-metal). Minimum Masonry Z.C. (Metal) Clearances Fireplace Fireplace k Sidewall 13" 331mm 30" 762mm c%bsr;beM I Side Facing 9.5" 242mm 12" 305mm aryj m Top Facing 12" 305mm 12" 305mm Side n 4s�be n Mantel 15.5" 394mm 24" 610mm ro Wall ��a��,9 o Front Hearth 16" 407mm 16" 407mm (does not (US) (US) include insert ---------- - - - - ----- - -- m extension "x") 18" 458mm 18" 458mm Canada Canada k / p Side Hearth 8" 204mm 8" 204mm q Front of Insert 36" 36" y 915mm 915mm `P x Extension Onto 3" 77mm 3" 77mm Hearth ti0/416 e �s f a'�h 'bie � x Figure 3 Hearth Requirements • Must extend 16" (USA)or 18" (Canada) in front of the insert and 8" on both sides. • Must be non-combustible and at least .018"thick (26 gauge) Masonry Fireplace Requirements CANADA ONLY: The fireplace insert must be installed with a continuous chimney liner of 6" diameter extending from the fireplace insert to the top of the chimney. The chimney liner must conform to the Class 3 requirement of Can/ULC S635, Standard Lining Systems for Existing Masonry or Factory- Built Chimney &Vents, or CAN/ULC S640, Standard for Lining Systems for New Masonry Chimneys. • Chimney must have a clay tile liner or a stainless steel liner(positive connection). • Entire fireplace, including chimney, must be clean and undamaged. Any damage must be repaired prior to installation of the insert. • Chimney height: 15' (4.5M) minimum; 33' (10M) maximum. • Entire fireplace, including chimney, must meet local building requirements. • The fireplace insert must be placed on a masonry hearth built to UBC standards. © Travis Industries 100-01233 4141211 The Commonwealth of Massachusetts Z Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 ^M 4 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:THE FIRE PLACE Address:106 STATE RD City/State/Zip:WHATELY, MA 01093 Phone#:413-397-3463 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 10 employees(full and/ 5. ❑Retail or part-time).* 6. F1 RestaurantBar/Eating Establishment 211 1 am a sole proprietor or partnership and have no 7_ ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• []Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:MA RETAIL MERCHANTS GROUP WC INC, Insurer's Address:P.O. BOX 859222-9222 City/State/Zip: BRAINTREE, MA 02185 Policy#or Self-ins.Lic.#014005033601115 Expiration Date:1/1/2016 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 certifQy,, toderr tthe pains andp alties ofperjury that the information provided above is true and correct. Signature: t/` " Date: �P Phone#:413-397-3463 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia it of Northampton a, �_II X41 Massachusetts i A _ `y 0C'[ 5 f016 DZ 7&NT OF BUILDING INSPECTIONS :x in Street • Municipal Building s p� • _ Northampton, MA 01060 Electric,Plumbing&Gas Inspections 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: D Check# A Q6'-' PLEASE TYPE OR PRINT ALL J � INFORMATION ` 1. Name of Applicant: ' 0C'14-S 10 � I�� ril (°re - pp r Address: 106 ST�'f� ;� l�/i�f{ty �� Telephone: 11113 - 1377-3143 2. Owner of Property: KenAe-'1-,6 f'/ `A/C-l~ Address: sgOZ V�rj L-c-'rDS PA Telephone: 7/--s ' fir" 143'? 3. Status of Applicant: Owner 'Contractor 4. Type or Brand of Stove: G�:f y ,Z' If applicant is not the homeowner: Construction Supervisor's License Number 9 yo/ Expiration Date 14 Home Improvement Contractor Registration Number /f0V 77 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 contained herein is true and accurate to the best of my knowledge. DATE: APPLICANT'S SIGNATURE sip -W DATE: Q HOMEOWNER'S SIGNATURE2Lt• Z t. 6AZy APPROVED DATE: BUILDING OFFICIAL 592 SPRING ST BP-2016-0463 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 15B-011 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-2016-0463 Project# JS-2016-000762 Est. Cost: Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin BERNARDSTON FARMERS SUPPLY 99401 Lot Size(sq.ft.): 26005.32 Owner: FISHER KENNETH C&MARY T CAYO Zoning: URA(100)/WP(62) Applicant: BERNARDSTON FARMERS SUPPLY AT. 592 SPRING ST Applicant Address: Phone: Insurance: 43 RIVER ST (413) 648-9311 O WC BERNARDSTONMA01337 ISSUED ON.10/6/2015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL LOPI REPUBLIC 1250 INSERT 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 10/6/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner