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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1 146 Route 28 SEP 15 2025
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261 BUILNTNT
CONSTRUCTION ADDRESS:
OWNER. RtlCI e.NtKely 7/✓041,4(_,5 h t 7,2 4/ R-5-9 vs'6'7
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CONTRACTOR. 4ll U ¢CJ'ti V (y// V
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EMAIL: j/ e(-,t-s 6 170 Vu1NGO,f nDA
/Residential Commercial Est.Cost of Construction S gsOO-
Homeowner is Applicant? \es i� No
Home Improsement Contractor Lic.# Construction Supersisor Lic.#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
v—
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares Insulation Temporary Mobile Home
Temporary Construction Trailer Demolition-Interior only *Demolition Raze Structure
Solar System ESS System Chimney Fence
*Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical review
'The debris will be disposed of at _
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct o the best of my knowledge and belief. I understand that any false answensl
will be just cause lie denialyor rtrp ovation of my license and for prosecution under M.(i.L.Ch.26g.Section I. /
.Applicant's Signature, (/` D /�/n(�`/-�// Date O.?..AcA0 0�
Owners Signature(or atnchment)�a HV �/� Date: 69//S/!!!
:\ppnwed lfy-. C� Date:
Building Official tor designee/ _—
Res 6 24
The Commonwealth of Massachusetts
Department of Industrial Accidents
— :w11111Office of Investigations
TM' Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiowndividual): Roizertfl �y
Address: 71't/40ha ugid Ra4,J
City/State/Zip: Sar 1 -,•J,�au�h /Vakr od6k,y Phone #: 7 oZdie g-53; 11S4-7
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 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
workingfor me in anycapacity. employees and have workers'
t 9. ❑ Building addition
[No workers' comp. insurance comp. insurance. 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ eP
3.01 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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:
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 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 certti�fy under
eer the pa' a penalties of perjury that the information provided above is true and correct
Signature: 1Qo s Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
i❑Board of Health 21:Building Department 312City/Town Clerk 4.1=1 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#:
_ VERMONT CASTINGSWood- Burning�
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Montpelier II Wood-Burning Insert in Majolica Brown
547
Watching the flames and feeling the warmth of a wood fire is an experience that
never gets old. The Montpelier II and Gifford wood-burning inserts maintain that
.p--- timeless appeal and highlight large, unobstructed views of the fire, turning your
r existing, drafty fireplace into an efficient centerpiece.
_ --\\ Vermont Castings provides more than heat. It's the warmth that unites. Proudly
crafted and tasted by our artisans in Vermont, no detail is too small, no element
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insignificant. The timeless designs and furniture-quality finish set the scene for
intimate memories.
Montpelier II • Montpelier ll Gifford
Peak BTU/hr Outputs 56,000 37,400
Heating Capacity2 1,000 - 2,400 sq ft 650- 1,300 sq ft
—71 I ;
Maximum Burn Time 7 hrs 6 hrs
III I I.
'I --- —I _
Efficiency3 77% LHV/ 71% HHV 70% LHV/65% HHV
II I Emissions 1.85 g/hr 1.9 g/hr
i
Firebox Capacity 2.4 cu ft 1.5 cu ft
q
,I - I Recommended Log Length 20" 18"
- Actual Weight 400 lbs 335 lbs
- - Blower System 200 CFM 200 CFM
Gifford
3 Easy Steps To Upgrade Your Existing Wood-Burning Fireplace
S T E P 1 : Measure Your Existing Fireplace
The height,width and depth of the existing fireplace opening is -
needed to ensure selection of an appropriately sized insert: _ A 1
A.Fireplace front width D. Fireplace Depth I I 1 I
B. Fireplace front height E. Hearth to mantel height B D E
C. Fireplace back width (based on a 12"deep combustible mantel)
D
Minimum Fireplace Opening
A B C D D E
FRONT WIDTH FRONT HEIGHT BACK WIDTH DEPTH DEPTH HEARTH TO
(STEEL SURROUND) (CAST SURROUND) MANTEL HEIGHT
MONTPELIER II 32" 23-3/8" 24-1/8" 18-1/8" 17-7/8" 47-3/4"
(813 mm) (594 mm) (613 mm) (460 mm) (454 mm) (1213 mm)
GIFFORD 27" 19-1/4" 24-1/2" 15-15/16" 15-5/8" 44-3/4"
(686 mm) (489 mm) (622 mm) (405 mm) (397) (1137 mm)
S T E P 2: Select a Surround S T E P 3: Customize Your Insert
Surrounds remove the gap between the fireplace insert and Make it your own.Select stunning finish options
existing fireplace opening. Choose from numerous sizes and and accessories.
styles for a unique look.
1.111.1 rill
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CAST IRON STEEL CLASSIC BLACK MAJOLICA BROWN
Small:38-7/8"x 26-1/4"(Gifford) Large:51"x 34"(Montpelier II only)
Large:44"x 30-1/4"(Montpelier II) Medium:43"x 31-1/8"(Monpelier II and Gifford)
Small:38-1/4"x 28"(Gifford only)
Specifications
A B C D E F G H
Montpelier II 44"(1118mm) 30-1/4"(768mm) 13-5/8"(346mm) 23-1/8"(587mm) 23-3/4"(603mm) 31-1/2"(800mm) 23-5/8"(600mm) 17-5/8"(448mm)
Gifford 38 7/8'(987mm) 26-1/4"(667mm) 11-3/4"(298mm) 19"(483mm) 19-3/4"(502mm) 26-1/2"(673mm) 24"(610mm) 15-5/8"(397mm)
FRONT VIEW SIDE VIEW TOP VIEW
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Scan to learn more
about our wood inserts For full warranty details,visit✓✓wN3.forgenflarne.cum
.
• F:° 0 1:BTU/hr output 1st hour output uses high bum efficiency number.BTU/hr output will vary depending on the type of fuel used and moisture content of the fuel.2:See your local Vermont Castings
authorized dealer for help in determining the product that best suits your heating needs,based on climate and home efficiency.3:Weighted average LHV(Low Heating Value)efficiency.HHV(High
r
Heat Value)efficiency used to qualify products for Tax Credit beginning in 2023.
IMPORTANT-READ BEFORE YOU INSTALL!-Refer to the Owner/Installation Manual for complete clearance requirements and specifications.The images and descriptions in
_ this brochure are provided to assist you in product selection only.Vermont Castings is a registered trademark of Hearth&Home Technologies.Product specifications and pricing
r •t p 1 subject to change without notice.Fireplace,stove and insert surfaces get extremely HOT and can cause burns if touched.Keep a safe distance away.
CI 4r....17
. .4A.• To learn more visitforgenflame.com/pages/fireplace-safety
iiif 0 Fn in FORGENFLAME.COM
V MT-1028-0324