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EXPRESS BUILDING PERMIT APPLICATI 1
TOWN OF YARMOUTH ,�y E C E I V °#
Yarmouth Building Department _ !
1146Route28 1P , � d
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South Yarmouth, MA 02664 i (!
(508) 398-2231 Ext. 1261 BU LoING DEPARtr
by ,
CONSTRUCTION ADDRESS: .... � �r
ASSESSOR'S INFORMATION:
Map: la Parcel: 7,
OWNER. v72-
14
PRESENT DRES TEL. #
CONTRACTOR: „ k = , �7S g
AIME f JAILIi D `� TEL.#
❑Residential ` 'Commercial Est. Cost of Construction$
Home Improvement Contractor Lic.# Construction Supervisor Lie.# �T_
Workman's Compensation Insurance: (check one)
0 I am the homeowner XI am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: ` Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove o>c )..
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
_ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herei. containe. . e true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for deni. . Ar, . on of/icense - for pro:-cution under M.G.L.Ch.268,Section I.
Applicant's Sip atur' / �i7,9i / Date: �' ,147/P.Z -
Owners Signature o .tta meat /��j/ ,r, „/ 4 (� Date: / /%4(77-‘21
Approved By: . : � ' Date: "//'%ZG�
Buil =e 0 1 (or designee) ` JAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 11 No
''� , The Commonwealth of Massachusetts
,., l It Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
'�M ••
•••ow" www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apelicant Information Please Print LeoiIy
b
Name (Business/Organization/Individual):
Address: _Va _ -7
City/State/Zi • r �L �j Phone 4: 1-9e:. c. C ,
Are you an employer?Check the appropriate box:
_ Type of project(required):
1.—.I am a employer with employees(full and/or part-time).* 7. New construction
am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself 9. ❑ Demolition
y [No workers'comp. insurance required.]'
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition
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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
These sub-contractors have employees and have workers'comp. insunance.t.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(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 4 or Self-ins.Lic. 4: 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 u er tlz s s nd p ti perjury that the information provided above is true and correct.
Signature: / ,',�l_/� Date: e'20 /�j/ ,,
Phone 4: `"7'. 0 sg�o1 4�
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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Avalon Wood Stoves
SELECT YOUR FREESTANDING STOVE Sating,hewing mid petfortnonte spec lions.
' IMPORTANT NOTES:With any wood burning Fireplace,Stove or Insert,this appliance is extremely hot during operation. j
Read and understood all the operating instructions before using this appliance.
Niiiiims4 ...A NlER c u,v71
Hoag ** 600 b 1,200 sq.ft. 1,280le 2,008 sq.ft. 100 to 1,800 sq.it. 1,500 is 2,500 sq.
Need War(condoled) 66,800 WON 72,400 bm's/In 71,100 6b's/le 74,300 6ro's/br
OvelaaEfhdercy** Upb79.6X - Ditto 7U% Upb77.6% Itp°75.2X
Max,Bunt Time** Up te 8 lours Up b 10 hews Up Pi 9 lours Up b 12 Ieuts
Manama Leg Sae Up to lr u,le 18' Ilp fe r Unto 24'
90'flies 90'Flue 90° 90'flee
With 23 5/8` 24, pi.- 253/4' 29 3/r
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Height(Pedestal) 29 3/4' 301/2' 331/C 33 3/r
Depth 14 5/8' 231/2' 19 3/r 201/2'
Hue D'ieselr 6' 6' 6' 6'
Weight 243 bs.(win hugs) 438 is.(wHh legs) 345 lbs. 465 lbs-
Steel lhidaessIto 1/4' 5/16' 1/4' 5/16'
Steil ilrdaess Unhldy 3/16' 3/16' 3/16" 3/16'
Frebee Ceponly 1.6 cs.ft. 2.2 co.ft. 1.8 at.ft. 1 3.1 a.ft.
*CURD WOOD test hails showing mastic BTUs using cad Weal logs with►egular idgeing. Heed mdpd wi Met m dhirnney ehdt as well or type,mospre emdent and sue of wood
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C-SinebtonerWei 10" 10' 15' . 61/2', 11' 71/2 91/2' 71/2'
D-Pipe to Side Wel 27- 261/2' 24' ` 211/2' 24' 231/2 27 3/4' 271/4'
E-Few Is lerk Wet 191/4' 111/4' 17 3/4" 61/2', 15 3/4' 101/4' 17 3/4' 121/4'
F'Rpebcow" 173/4' 171/4' 24' : 15." 20' 16' 21' 181/Y
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6-Stove Road 16' 16' 16" 16' 16' 16'
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17
2/9/2029 Safety Information—AJ Hearth Originals
MENU •MANUFACTURING, LLC
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HOME SAFETY; 1F RMAT!Oty
AJ Manufacturing is committed to safety
Hearth safety begins with protecting combustible materials and exposed surfaces in your home from the heat
produced in a fireplace or stove.To ensure your protection,all hearth appliances are tested to the applicable
Standards of Underwriters Laboratories(UL).AJ ember protection floor protectors are tested and approved to UL
1618-2009 by Omni Laboratories of Portland,OR.AJ thermal protection floor protectors are tested and approved to
UL 1618-2009 by U.L.Laboratories.The thermal protection floor protectors are a UL listed product.
The UL 1618-2009 Standard
The UL 1618-2009 standard requires a series of tests including: Thermal Resistivity testing,an Accelerated Aging
test,Radiant Panel test,Burning Brand Test,Impact and Strength tests. We can state with confidence that our floor
protectors will give you years of safe and durable service.
In 2009,Underwriters Laboratories adopted UL 1618-2009 as the standard for Wall Protectors,Floor Protectors
and Hearth Extensions. AJ,and other manufacturers of hearth protectors,worked closely with UL to develop this
standard.The result is a system that simplifies matching the appropriate floor protection to the hearth appliance.
Floor protectors are divided into two basic categories-Type 1 Ember Protection and Type 2 Thermal protection.
Type 1 Ember Protection
Many modern hearth appliances do not require thermal protection(heat resistance)on the floor. These products
installations guidelines may specify a non-combustible material or ember protection. Over time stove installation guides
will use the new"Type 1 Ember Protection"designation exclusively. A Type 1 floor protector provides protection
from accidental ash or ember spillage.A Type 1 protector has thermal resistance but,for the purposes of UL-1618
Type 1 Ember Protection is considered to have a thermal resistance of R=O.
View our printable Type 1 installation guide
https://ajhearthoriginals.com/support/safety-information/ 1/3
2/9/202t Safety Information—AJ Hearth Originals
Type 2 Thermal Protection
• If any amount of thermal resistance is required by your hearth appliance,then Type 2 Thermal Protection is
necessary.Older appliance installation guidelines may express the requirement as a"k"factor,an"R"value,or
thicknesses of millboard.Over time stove installation guides will use the new"Type 2 Thermal Protection"
designation exclusively and express the thermal resistance requirement as"R-value."AJ Type 2 floor protectors have
a minimum R value of R= 1.1.R values up to R= 10 are available.Check with your hearth retailer to ensure you
choose a floor protector that meets or exceeds the thermal protection specified in the appliance installation guide.
View our printable Type 2 installation guide
Protecting your home.
PLEASE NOTE:There are still a few manufacturers of floor protectors who do not submit their product for safety
labeling.Look for the safety label.Floor Protectors tested and approved to UL 1618-2009 are clearly marked with
the manufacturer name,model,and will be designated as Type 1 Ember Protection or Type 2 Thermal Protection.In
addition,tested Type 2 Thermal Protectors will specify the"R"value of that particular model.Older floor protectors
that were labeled to the old UL Subject 1618 prior to 2009 were not tested for thermal protection.Should the
unthinkable happen and an accident occur,your insurance company will be looking for a safety label.
AJ
USEFUL LINKS
https://ajhearthoriginals.com/support/safety-information/ 2/3
2/9/202@ Safety Information—AJ Hearth Originals
BBB A+Accredited
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ACCREDITED
BUSINESS
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https://ajhearthoriginals.com/supportisafety-infonnation/ 3/3
2/9/2020 Signature Series—AJ Hearth Originals
•
MENU •MANUFACTURJNG, LLC
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HOME ;' SIGNATURE SERIES
The flagship line of AJ floor protectors
Stormy Sky(PCSS)
Shown with Gun Metal Gray Premium Edge 6"Pedestal Tile Faced
hops://ajhearlhoriginals.com/products/signature-series/ 1/10
. 2/g/2026 Signature Series—AJ Hearth Originals
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Harvest Moon(PCHM)
Shown with Textured Bronze Metal Edge 6'Pedestal with Dark Walnut Stain
AK---
Brazilia(PCBZ)
Shown with Black Metal Edge 6'Pedestal with Tricorn Black Lacquer
httpsJ/ajhearihoriginals.com/products/signature-series/ yi p
2/9/2020, Signature Series—AJ Hearth Originals
•
Woodland Black(PcwB)
Shown with Black Premium Edge 6"Pedestal Tile Faced
About Signature Series Floor Protectors
Pedestals are a very popular option for AJ floor protectors.Not only are they attractive but they serve the
practical purpose of raising your stove for easier loading and cleaning.AJ pedestals are the strongest in the
industry;designed expressly to support the considerable weight of a stove.The Signature Series is made with
all the quality features and options of our Hearth Originals plus all the benefits of an attached pedestal.
AJ ember only protection Signature Series hearth pads were tested and approved by Omni Research to UL
1618-2009.Our AJ thermal protection Signature Series hearth pads are tested and approved by U.L.
Laboratories with a"R"rating of 2.1.This is an UL listed product.
httpsi/ajhearthoriginals.com/products/signature-series/ 3/10
2/9/202@ Signature Series—AJ Hearth Originals
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Bottom view of a corner hearth Thermal Pedestal
The AJ Difference
Every AJ pedestal is permanently attached to the hearth.We found that add-on pedestal"kits"were just not strong
enough to support the weight of many stove models.Our pedestals are reinforced and braced to handle the weight of
a stove without sagging or warping.
All AJ pedestals are custom made.3%"and 6"heights are standard but they can be ordered in heights from 112"to 6"
high in%"increments(taller by quote).Signature Series hearths come to you completely assembled and ready to
install,saving you time and installation cost.
Choose from any of the Hearth Originals tile colors with Metal or Aluminum Edging.Metal Edge hearth pedestals are
finished in Tricorn Black unless a wood stain is specified.
Premium Edge Options
httpsJ/ajhearthoriginals.com/products/signature-series/ 4/10
2/9/2020 Signature Series—AJ Hearth Originals
Single LOP Corner Dimensions
Corner Hearth Pad
Size A B C D
32 x 32 32-3/4 22 14-3/4 38-1/4
36 x 36 36-3/4 25 16-3/4 43-1/2
41 x 41 41-3/4 29-1/2 16-3/4 50
48 x 48 48-3/4 36-1/2 16-3/4 60
https://ajheaAtxxiginals.corn/products/sgnature-series/
1/2