HomeMy WebLinkAboutBld-20-003219 1
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Office Use Only
. 4 e y sp. Permit#
O mil.'. H. Amount v k
Permitrc expires 180 days from
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issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 C
� ZSouth Yarmouth,MA 02664 K o. 1 r
CONSTRUCTION ADDRESS: ! f �V/rain (Ai 11; A ted
AlSSESSOR'S INFORMATION: / AYE' 0 4,46
Map: Parcel: ♦♦♦
OWNER: tki l S Al?\ •'vo to K 19 (canbeuc MM. 1yacm44/4/!-)d 4/ N Y31092
NAME PRESENT ADDRESS' TEL. #
CONTRACTOR: N1 A
NAME MAILING ADDRESS EL.#" r� �"�
R7 ,esidential ❑Commercial Est.Cost of Constructii,,l I /fryf,
Home Improvement Contractor Lic.# / ,"A Construction Supervisor Lic.# /'r/4
Workm 's Compensation Insurance: (check one)
am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance ",�
Insurance Company Name: /4 Worker's Comp.Policy# r/ /4
WORK TO BE PERFORMEDV
Tent Duration (Fire Retardant Certificate attached?) Wood Stove / 4,
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for lik Pool fencing
*The debris will be disposed of at: / 14" r
‘1 C'-'e..."7e74"3/ 4'4— Afr69 41/ 14"(
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial orr�evo'cationnf my lice se and for prosecution under M.G.L.Ch.268,Section 1. /
7 Applicant's Signature: Date: / /�
Owners Signature(or attachment) > Date:
Approved By: �+ Date: /2 —5 /f
Building 0 al esignee) EMAI DRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes i_l No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes El No G Yes 9 No
, -
-a qp. ..•-• •
The Commonwealth of Massachusetts
Department of Industrial Accidents
_dfl=` 1 Congress Street,Suite 100
Ec Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information 1> Please Print Legibly
Name (Business/Organization/Individual): SS 0.14/" l i re
Address: J 9 ((0„lig etty
City/State/Zip: A40 i Phone#: c T S11 ) 3
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical 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'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'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:
Policy#or Self-ins.Lic.#: 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 under .e pains-anal penalties of perjury that the information provided above is true and correct
Date: /a) /r/9
Phone#: K Sic 19 S 3
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#:
H1200
HAMPTON®
Wood Cast
Insert
Owner's & Installation Manual
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www.hampton-fire.com
French Manual: http://ow.ly/ZvrQj
Manuel en Francais: http://ow.ly/vrQj
ested by:
C (Tii Installer: Please complete the details on the back cover
and leave this manual with the homeowner.
Homeowner: Please keep these instructions for future reference.
Intertek
919-555c FPI FIREPLACE PRODUCTS INTERNATIONAL LTD. 6988 Venture St.,Delta,BC Canada,V4G 1H4 08.02.18
4 I safety decal
This is a copy of the label that accompanies each #je as,
HI200 Wood Insert.We have printed a copy of i- 6 E E a,a,,,d a)e
the contents here for your review. V i oQ
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NOTE: Hampton units are constantly being �Wff i ❑
improved. Check the label on the unit and if i 1 .1 I ❑
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4 I HI200 Hampton Wood Cast Insert
8 installation
MASONRY AND FACTORY BUILT FIREPLACE CLEARANCES
The minimum required clearances to combustible materials when installed into a masonry or factory built fireplace are listed below.
A B C D E F G H
15"(381mm) 20"(508mm) 14"(356mm) 7-3/8"(187mm) 16"(406mm) 1.1/2"(38mm) 6"(152mm)[USA] 19"(483mm)
[USA] 8"(203mm)[CAN]
18"(457mm)
[CAN)
Side and Top facing is a maximum of 1.5"thick.
Floor protection must non-combustible,insulative rw✓7sIn,VG V�i.1It� 9i uV 1 .prt ,u N 1 II llu&{3r�s1.4I •a I°l.rlw
material with an R value of 1.1 or greater.
* If the hearth extension is flush with the floor(F) •
it must extend 19.5"in front of the body face B
(E).
Note: Hearth Extension Width (G) is meas-
ured t ,
from edge of fuel door to side of 1" " '' ,4 ° "f "1 It��1m a rtmtlp°
11
hearth.
***Mantel depth,maximum of 10"(254mm) 1 A • �' . * D
** A non-combustible mantel may be installed
at a lower height if the framingis made of e E
9
metal studs covered with anon-combustible f(®il •
board.
Thermal floor protection is not required if the unit is • I+i1 ' y1 ;" t ,�
raised 3.5"minimum(measured from the bottom of F ' • i' (
the stove).However,standard ember floor protection T
is required.It will need to be a non-combustible mate- Clearance diagram for installations
rial that covers 16" (406 mm)in the US and 18"(450
mm)in Canada to the front of the unit and 8"(200 Floor Protection
mm)to the sides.
lithe unit is not raised,thermal floor protection required Please check to ensure that your floor protection and hearth will meet the standards for clear-
is 18"(450 mm)in the US and Canada. ance to combustibles.Your hearth extension must be made fronn a non-combustible material.
HOW TO DETERMINE IF ALTERNATE
FLOOR PROTECTION MATERIALS ARE ACCEPTABLE
The specified floor protector should be 3/8" Step(b): DEFINITIONS
(18mm) thick material with a K - factor of Calculate R of proposed system.
0.84. 4"brick of C=1.25,therefore Thermal Conductance:
Rbrick=1/C=1/1.25=0.80
The proposed alternative is 4"(100mm)brick 1/8"mineral board of k=0.29,therefore C = Btu = W
with a C-factor of 1.25 over 1/8"(3mm)mineral Rmin.bd.=1/0.29 x 0.125=0.431 (hr)(ft2)(°F) (m2)(K)
board with a K-factor of 0.29. Total R=Rbrick+Rmineral board=
0.8+0.431 =1.231. Thermal Conductivity:
Step(a):
Use formula above to convert specification Step(c): k = (Btu)(inch) = W = Btu
to R-value. Compare proposed system R of 1.231 to (hr)(ft3)(°F) (m)(K) (hr)(ft)(°F)
R=1/k x T=1/0.84 x.75=0.893. specified R of 0.893.Since proposed system
R is greater than required, the system is Thermal Resistance:
acceptable.
R =(ft2)(hr)(°F) = (m2)(K)
Btu W
8 I H1200 Hampton Wood Cast Insert