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EMPRESS BUILDING PERMIT APPLICATIO NOV 08 2018
TOWN OF YARMOUTH
BU .a r. .:A . MENT
Yarmouth Building Department BY: ge
1146 Route 28
South Yarmouth;MA 02664 ,....—.
(508)398-2231<Ext. 1261 ..( a A/L, mit,vr'N 444
CONSTRUCTION ADDRESS: � 4-3 9 cryT
ix/ /go c'1ur' O.-C6 S/
ASSESSOR'S INFORMATION:
Map: Parcel: c-10- /4sr sry .0 v 7 / ALi
OWNER: 44 Vie /(/i4ol/e �7 0%0,7 0/Ai /oitJT e :mod'7zoS'YYo
NA, PRESENT ADDRESS TEL #
coNTRAcroR: e-4Vrt_tc/CC 414/2/00N4,44 v 0�3.d /PP veAee4eta
NAME 02 � AQovc✓.Cr ,5'4' cv1cN T. MA OLINL # / P
// I / U—
'O�esidential ❑Commercial � Est.Cost of Construction a /" r
Home Improvement Contractor Lie.# el, 0. t.6? Construction Supervisor Lie.# �" • o ,V 9 //
Wort s Compensation Insurance: (check one)
�C I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensatlon Insurance
Insurance Company Name: - Worker's Comp.Policy.
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacementdoors:• #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )ReplacingTlike for like Pool fencing
'The debris will be disposed of at: , `� At cif /KAP-z rr2 efTA 77041J-, ,(�.�/d ���N
• don of Facility Ofre..eN a A/ti-. "Coal 'v
[declare under penalties of perjury that di ..herein are true and correct to the best of my knowledge and belief 1 understand that any false answer(s)
will be just cause for denial or . :, of cense`.. ..� (on under M.O.L Ch.26S.Section I.
Applicant's Signature: /
„id
/ /r / Dater // D "'
Owners Signature(or attachment) Al, Date:
Approved By: Vii! .SGiPirdI • Date•.. . /7— 9/8 .
Buiidin: ...... / ,<gnee) n n o aRESS: ..
Zoning District
Historical District: d Yes ❑ No -Flood Plain Zone: ❑ Yes ❑ No
Water Resource Flotation District Within 100 ft.of Wetlands: -
❑ Yes 0 No 0 Yes . 0 No
__ . The Commonwealth of Massachusetts
I :—�/ Department of Industrial Accidents
t Milt, l_ t 1 Congress Street,Suite 100
_] _l_ Boston,MA 02114-2017
'",a.�,,s��s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): /✓/�A (// �IC14.E
Address: / C- ,44ni/Ai n/O C/Air/e. 0 /
City/State/Zip: 1 o y 1 ettOvf/J 414 Phon c V rote-7 /0 4rV�
Are you an employer?Cbeck the appropriate box: Type of project(required):
l.❑1 em a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]: 9. ❑Demolition
4.I rs'am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 ❑ Building addition
YrrYYY"'''''tttt'ansurethat all contractors either have workecompensation insurance or are sole 11.❑Elect ical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs /
These sub-contractors have employees and have workers'camp.insurance.:
14yyy��� EL/
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. ther'
152,§1(4),and we have no employees.[No workers'comp.Insurance required.] .t (
*Any applicant that checks box#i 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 andJob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.If: 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify wade pains nd penalties of perjury that the information provided above is true and correct
-/L.- Si¢nature: G m vb CCI4j Date:
Phone#: CCI
4j
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#:
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CPSC certificate of Conformity
This shipment contains one or more tats a mandatory sarety dard. Please consider this
document as certification that the product contained herein meets such standard(s).
Product Description: Wood Burning Stove • Testing Organization Certifying Compliance:
IntModels: F 602 CB, F 118, F 100, F 3 CB, F 370, F 400, 84331 Murpty� DriveServices, Inc
F 500, F 600, F 45, F 50 TL, F 55, C 350, C 450, C 550 CB Middleton,WI 53562 -
Tel:608.836-4400
Manufacturer: Jetta North America, Inc.
55 Hutcherson Drive
Gorham, Maine 04038 Applicable Standard: '
Tel:207-591-6601 Coal and Wood Buming Applianc s-Notification of Performance
Date of Manufacture: 11/17/15 N 16 CFR Part 1406
Test Date: F 602 C3-119/97. F 118-2/28�F 100-3120/02 Individual Responsible for Records:
F 3 CB-2/21/03 F 370-11/26/08 F 400-6/16/00 F 500-3/16/9Jame'9 JaHolliday, Documentation Mgr.Jratul
F 600-10/29/98 55 Hutcherson Drive
Inc.ica, ur
F 55- 12/24111 F 45- 12/28/12 F 50TL-X30/10 Gorham, Maine 04038 U.S.A. rn
C 35915/19/06 C 450 -7/30/02 F 550 CB-10/18/07 Te1:207-591 6641 1 3
'
lacgtoo , e Stove Place II Invoice ,
2-C Harold Street
11 HarwichPort,MA 02646 DATE INVOICE#
HARWICH PORT (508)432-5977 (508)432-9873 - Fax
9/27/2018 14671
www.stoveplace.com
BILL TO SHIP TO
David Nadle
39 Captain Blount Road
South Yarmouth,MA 02664
I
P.O. No. TERMS SOLD BY Phone No. fee for returned checks
C.O.D. 508-760-5220
QUANTITY DESCRIPTION RATE AMOUNT
1 Jotul F3CB 42,000 BTU Matte Black Wood Stove 2,009.00 2,009.00T
Serial#
Discount -10.00% -200.90
1 Jotul 3CB Screen 136.00 136.00T
DuraTech Pipe (Wood) & DVL 1,796.00 1,796.00T
1 Permit Fees 75.00 75.00
1 Installation 550.00 550.00
,--1 Dump Fee for Removal of Old Stove 50.00 50.00
1 Deposit/CHECK#1606 -500.00 -500.00
1 Installation Date: Monday Nov. 19th PM
Type of Installation:Roof/
Type of Foundation:Slab
VENT OFF THE REAR OF STOVE
Sales Tax Massachusetts 6.25% 233.76
i
Thank you for your business!
Total
E-mail info@stoveplace.com $4,148.86
./1 • LARRCAR-01 KDOYI
A`ORn CERTIFICATE OF LIABILITY INSURANCE DATE,MMD°"""'
09/19/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of suchpp endorsement(s).N
PRODUCER NPM€ACT
Rogers 8 Gray Insurance Agency,Inc. • PHONE FAX
434 Rte 134 (AIC,No,EH): . 1 IWC,NoC(877)816-2156
South Dennis,MA 02660 'ut alass;mall@rogersgray.com
INSURERISI AFFORDING COVERAGE NAIC N
INSURER A:Main Street America Assurance Company 29939
INSURED INSURERB:NGM Insurance Company 14788
•
• Larry Carbonneau INSURER C:Associated Employers Insurance Company 11104
dba Stove Place II
2C Harold Street INSURER D:
Hanvlchport,MA 02646 INSURER E:
•
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTNATHSTANDING 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
jI TR TYPE OF INSURANCE ADDLSWVD POLICY NUMBER IMMID�D%Vyy) (MM DDY UP
I LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,0
CLAIMS-MADE El OCCUR X BPT2173L 1011012018 10/10/2019 DAMAGED RENTED 500,01
ME. P A one•.non 10,0
-- • PERS.NA &ADV INJURY 1,000,01
GEN'L AGGREGATE LIMIT APPLIES PER: 1,51 2,000,01
RPOLICY❑JECT Z LOC • PReiiT COMP.PA 2,000,01
OTHER: S
B AUTOMOBILE LIABIUTY $ 1,000,01
— ANY AUTO X M9T1263K 10110/2018 10/10/2019 BODILY INJURY Per.. •n $
_ OWNED ONLY X SCHEDULED
AUTOS
'AIMAUTOSUpNINyµ�N'EEpp BODILYOINJURY Per accident S
X AUTOS ONLY x AUTOS ONLY PPerraccc,Eml AMAGE S
B XS
._ UMBRELLA UAB OCCUR • __ $ 3,000,01
EXCESS LUIS CLAIMS-MADE X CUT1283K 10110/2018 10/10/2019 AGGREGATE 3,000,01
DED X RETENTIONS 10,000
f
C AND EMPLOYERS'LIABILITY
X STATUTE• ERH
ANYpPROPRIETOR,PARTNERIEXECUTIVE YIN X TBD 09108/2018 09/0812018 E.L.EACH ACCIDENT S 500,01
QFNFICCE ry oAIEFA EXCLUDED? I N NIA 500,01
If yes,atolyIdescribeNH) E.L.DISEASE-EA EMPLOYES E
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S $00,01
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101 Additional Remarks Schedule,may se mtichad ammo apace Is Nooks)Larry Carbonneau is covered by the worker's compensation policy.
Certificate holder Is an additional Insured If required by signed written contract with the Insured for General Liability.
Eastward Companies Business Trust and/or Eastward Homes Business Trust and project owner together with their subsidaries,affiliates,employees,agents
members and directors ATIMA are listed as additional Insured If required by signed wrItten contract with the insured for General Liability.
•
CERTIFICATE HOLDER CANCELLATION
•
' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Eastward Companies
• THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
155 Crowell Rd. ACCORDANCE WITH THE POLICY PROVISIONS.
Chatham,MA 02633
AUTHORIZED REPRESENTATIVE ' ''.I
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserver
The ACORD name and logo are registered marks of ACORD •
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Commonwealth of Massachusetts
Division of Professional Licensure
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V Board of Building Regulations and Standards
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Constructiontiperyisor
CS-015911 ,,,,,,,- , inires:03/07/2020
LAURENCE dARBOONSic -
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484 LONG PO,EIROWC,
HARWICH MA paws "-- ;•,..
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Commissioner CAL
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...9Z Fa-neneviawzre.tlageraiaalasteas.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE,:IndMduel
Realstrificrik frolratfOri
11/02/2020
LARRY FCARBC -----f„ 7.
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LARRY F.CARBAW__47 . 612-e-S-r--
484 LONG POND litiht2-5
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HARWICH,MA 02645'^ s
Undersecretary
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139676-R06 F3 CB 1h8
4.o Clearances to combustibles
Floor Protection Clearances to walls and ceilings
Floor protection under the Jotul F 3, must be any The following clearances have been tested to UL and ULC
non-combustible material with an insulative standards and are the minimum clearances specifically
R value of t.t. established for the Jotul F 3.(See next page)
1
The bottom heatshield(standardequipment)Isrequired In The following charts and diagrams give the required
all Installations. clearances you must maintain when installing the
Jptul F 3 near combustible surfaces.
Individual sections of floor protection must be mortared
together t,o prevent sparks from falling through to A combustible surface is anything that can burn(i.e.Sheet
combustible materials. Any carpeting must be removed rock,wall paper,wood,fabrics etc.).These surfaces are not
from under the floor protection. limited to those that are visible and also Include materials
that are behind non-combustible materials.
In the U.S.and Canada If you are not sure of the combustible nature of a material,
Theiøtul F 3 must be installed on a non-combustible surface consult your local fire officials.
extending a minimum of t6"for U.S.(46 cm for Canada)in
front of the stove and 8"(zo cm)on the remaining sides of Remember: "Fire resistant" materials are considered
the stove(measured from side and back panels). combustible;they are difficult to ignite,but will burn. Also
"fire-rated"sheet rock is also considered combustible.
This will result in a minimum floor protection of 39 cm D x Contact your local building officials about restrictions and
39 cm W.for U.S.,and too cm D x 99 cm W for Canada. installation requirements in your area.
See figure 12.
In a rear vent installation the floor protection must also Using shields to reduce clearances
extend under the stove pipe a minimum ofz"(5 cm)beyond Pipe shields:When using listed pipe shields to reduce the
either side of the pipe. connector clearance to combustibles,it must start i"above
the lowest exposed point of the connect pipe and extend
Fig.12 vertically a minimum of 25"above the top surface of the
2" stove.
(5 cm) Double wall pipe:Listed double wall pipe is an acceptable
alternative to connector pipe heatshields.
�
A Wall-mounted protection: When reducing clearances
through the use of wall mounted protection:
In the U.S.Refer to N FPA ztt,standard for chimneys,fi replaces,
A O A 39"U.S
(104 cm Can) vents and solid fuel burning appliances,for acceptable
materials,proper sizing and construction guidelines.
In Ca nada,refer to CAN/CSA-B365,insta llation code for solid-
%-----SV
olid-
fuel burning appliances and equipment,also for acceptable
materials,proper sizing and construction guidelines.
B
S • eittoant-• rear heatshield is standard equipment on
all Jotul F 3' . No ether stove mounted heat shield may
.4_ 39"U.S. _� be used.
(99 cm Can) /�/J�-,p
Hearth Protection D N V"
A:8"(20 cm) L
6:16"for U.S.(46 cm for Canada) —111 /) /J_
10 /
139676-R06 F3 CB t/t8
JOtul F 3 CB Clearances
Stove Clearances Unprotected Surfaces Protected Surfaces
Top vent/vertical per NFPA ztt or CAN/CSA-8365-M
Side Rear Corner Side Rear Corner
Rearheatshield with 24" 25" 18" 10" 14" 10"
Single wall pipe 61omm 635mm 46omm 255mm 355mm 255mm
Rear heatshield with 18" 10" 14" 6" 6" 6"
Double wall pipe or shields 46omm 255mm 355mm isomm 15omm 15omm
Stove Clearances Unprotected Surfaces Protected Surfaces '
Rear Vent/Horizontal per NFPA 211 or CAN/CSA-6365-M
Side Rear Corner Side Rear Corner
Rear heatshield with 24" 25" 20" 10" 25" 18"
Single wall pipe 61omm 635mm 51omm 255mm 635mm 46omm
Rear heatshield with 18" 14" 17" 6" 6" 6"
Double wall pipe or shields 460mm 355mm 43omm 15omm isomm 15omm
Connector Unprotected Surface Protected Surface
Clearances per NFPA au or CAN/CSA-B365-M
Singlewall pipe-vertical installations 18"(46omm) 6"05omm)
Double wall pipe-vertical Installations pipe mfgr.listing pipe mfgr.listing
Single wall pipe-horizontal installations 18"(46omm) 9" (23omm) 4 i A
Double wall pipe-horizontal Installations pipe mfgc listing pipe mfgr.listing -5
Dimensions In Inches represent U.S.requirements. O !
Dimensions In Millimeters represent Canadian requirements. Or �—
Wall protection is discussed in further detail on page i
to of this manual. 0
Iririll-
11
p ����'
A:Top to Mantel 34" 86omm
B:Top Side to o irn 20" 510 mm
C:Side to Side trimt3" 330 mm
glielP/r/
D:Side to Side Wall 24" 6tomm
Maximum Mantel Depth: ttt/2" 292 mm
Maximum Top and Side Trim Depth: 11/2" 38 mm
12