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Building Permit #597-2016 - 281 BEAR HILL ROAD 11/16/2015
BUILDING PERMIT of N°oT bg+ TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION h Permit No#: P—PI Date ReceivedAreD ��SSACHUS���� Date Issued: IMPORTANT: Applicant must complete all items on this page _ � RPn'nt T� 100" l earStruc�ur yeses rtbi _ iMAP` tJ . .�IPARCL.�� _ ;Z®NIIVGiI®fSTF2JCT iHist©rrclDisfrict 'tiye ono .T_ fM'aehine4'Sf op�Vifa9 w� .. TYPE OF IMPROVEMENT PROPOSED USE . Residential Non- Residential ❑ New Building "ne family ❑Addition ❑Two or more family ❑ Industrial J�Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑.Other O'Septic ❑�,Welli # ✓4��lood lamaW elands+ DWatershedDistnct p R �_< u pikWater/Sewera DESCRIPTIO ORK TO BE PERF ME o 5� (Y") Cr, 1�15P.P� I S r�5o Chi mne, I I VolL9 Y�5ss Identification fl se Type or Pri t Clearly -� OWNER: Name: 0�1 � ,(�/1ne- PhoneLon Ic�X 3 42 Address: 9b I Rd �(Cohtract®rfNarne r_- -. _ _ 4P{ho5e .i L� '4H''®melemprovement�GLicen`se:' _tEx ®ate z �a : � < - p ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING;S-W MIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED.COST--BASED ON$925.00 PER S.F. Total Project Cost: $ FEE:J $� Check No.: pt Na.:Receipt 2a:03 NOTE: Persons contracting with unregistered contractors do not have.access:to e g aranty n Signature of Agent/Owner Signature of contracr Location At No. �" 2C�t Date . - TOWN OF NORTH ANDOVER J Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Check# 29 6 7 3 Building Inspector Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TypF aF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r r Zoninc;,Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: m - Located_- 384 Osgood_ .. t _ 1RE►DEPARATMEN�T ETemp -®umpster onasite ,yes_{ . _ ino Street iLocated,att124IV1ain St eet 4F�i`reep�artment�sgnature%date W.®MMEN[TSw Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land areasq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i vya ❑ Notified for pickup Call Email e , Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of HJ.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 � NORTI� own of t fAndover to No. Tile * _ - �� �` h ver, Mass, �� als O COCMICMl WICK AOlt /PA��� S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ' B.A.*04 .... .N. . �......... ............... BUILDING INSPECTOR .................. ..... . .. has permission to erect g Foundation .......................... buildings . .�. ......... ` o Rough to be occupied as .....�. ... ..�. R ...I"�......� .. �.. Chimney provided that the person accepting this permit shall in every respect conform to the term the application Final p p p g on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ' UNLESS CONSTRUCT Si fe� Rough Service ............. ..... ............... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. S A L E S O R D E R PAGE:1 THE STOVE SHOPPE PHONE#: (617)823-5848 DATE: 10/10/2015 25 INDIAN ROCK ROAD, ROUTE 11 CELL#: ORDER#: 24911 WINDHAM, NH 03087 ALT.#: CUSTOMER#: 135109 Phone#: (603)537-0555 P.O.#: 5036,5044 CP: Tom F Fax#: (603)537-0556 TERMS: Cash LOCATION: 1 SALES TYPE: Work Order STATUS: Pending TAG#: TECH: Mario B BILL TO 135109 SHIP TO Brian Odonnell Brian Odonnell 281 Bear Hill Rd 281 Bear Hill Rd North Andover, MA 01845 North Andover, MA 01845 YEAR MFR MODEL NUMBER DESCRIPTION VIN/SERIAL# MILEAGE/METER 1: INSTALL MERRIMACK Tech: Tom F � ) MFR PRODUCT NUMBER DESCRIPTION ORD SOLD B/O PRICE NET TOTAL VC MERRICB Merrimack Wood Insert 1 0 $2,951.00 $2,951.00 $2,951.00 Classic Black S/N: MERRICBB150500104 VC NORCSCB Northfield cast iron surround 1 0 $633.00 $633.00 $633.00 in Classic **** LAB25 Install Wood Insert w/Full 1 0 $0.00 $0.00 $0.00 Liner LAB LABOR COST 6 Labor Cost for Install 1 0 $660.00 $660.00 $660.00 NEC L6251K-R6 6"X 25' Liner Insert Kit 316 1 0 $724.73 $724.73 $724.73 SS, 30 Degree Offset w/A Type ROC 6DP Damper Plate 6" 1 0 $44.95 $44.95 $44.95 RUT 76C Silicon CLEAR High 1 0 $13.50 $13.50 $13.50 Heat10.3oz Cartridge LAB note 1 0 $0.00 $0.00 $0.00 ********NOTE********** LAB NOTE 1 These parts represent a 1 0 $0.00 $0.00 $0.00 typical install LAB NOTE 2 However other parts may be 1 0 $0.00 $0.00 $0.00 require. PER Permit Permit&Processing Fee 1 0 $125.00 $125.00 $125.00 NED EK1248S-TBLK Ember King Standard 1 1 $142.00 $142.00 $142.00 Extension, Black 12"x 48" **** MiSC ek1248s 1 0 $0.00 $0.00 $0.00 HST 94-79700 MANTLE SHIELD: 1 0 $119.00 $119.00 $119.00 MORGAN/CLYDESDALE Parts Job 1: $5,413.18 Subtotal Job 1: $5,413.18 Thank you for your business! All material must be paid in full at time of pick up or delivery Please note that if you are using our installation services all materials and labor must be paid in full at time of installation. If the installation takes more than 1 visit$250 may be withheld until the job is complete. TOTAL PARTS: $5,413.18 TOTAL LABOR: $0.00 TOTAL EXTRAS: $0.00 SUBTOTAL: $5,413.18 Merrimack Large Insert Intr 7TT� • • • Z / L j� ^®I�TT Thank you for purchasing a Vermont Castings Merrimack Large Insert,an efficient wood stove carefully engineered to L 1 1\�' ` 1 1 bring you the latest in wood combustion principles and modern foundry technology. CASTINGS This stove transforms a traditional masonry fireplace into a powerful heater.You can count on years of comfortable heating and pleasurable fire-viewing if you operate and maintain it according to the directions in this Owner's Guide. This Insert has been tested and listed by OMNI-Test Laboratories of Portland,Oregon to ANSI/UL 1482 for the United States and ULC S628 for Canada.This Insert is listed to,and in compliance with,the standards set forth by the Federal Environmental Protection Agency,40 CFR Part 60.532(b),as stated on the permanent label attached to the MerrimackThis manual describes the installation and operation of this Insert.This heater meets the U.S.Environmental Protec- tion Agency's emission limits for wood heaters sold after July 1,1990.Under specific test conditions this heater has Large Insert been shown to deliver heat at a rale ranging from 10,750 to 31,780 BTU/hr. For more complete details on stove performance and specifications,please refer to Page 3. Homeowner's The Merrimack Large Insert is designed,tested and listed for burning wood.Do not burn other fuels. Installation or service of the Merrimack Large Insert should be performed only by a qualified installer,preferably NFI or Installation WETT(Canada)certified. Please read entire manual before you install and use your new Insert. and Operating Failure to follow these instructions may result in property damage,bodily injury or even death. Manual For Use in North America Save These Instructions for Future Reference Table of • The Merrimack Large Insert is designed, . tested and listed for burning wood.Do not Specifications.................................. 3 burn other fuels. SAFETY NOTICE:IF THIS APPLIANCE IS NOT PROPERLY INSTALLED,OPERATED AND MAIN- Installation..............................................................4 TAINED,A HOUSE FIRE MAY RESULT. Operation................................................................9 The Merrimack Large Insert is not listed for TO REDUCE THE RISK OF FIRE,FOLLOW THE INSTALLATION INSTRUCTIONS.FAILURE TO Maintenance.........................................................13 mobile home installations. FOLLOW INSTRUCTIONS MAY RESULT IN PROPERTY DAMAGE,BODILY INJURY OR EVEN Optional Accessories............................................16 Failure to follow these instructions may DEATH.CONTACT LOCAL BUILDING OFFICIALS ABOUT RESTRICTIONS AND INSTALLATION Replacement Parts...............................................17 result in property damage,bodily injury or INSPECTION REQUIREMENTS IN YOUR AREA. Warranty...............................................................19 even death. NATIONAL We recommend that our woodburning Proposition 55 Warning:Fuels used in gas,wood- This stove has not been tested with an FIREPLACE hearth products be installed and serviced burning or oil fired appliances,and the products of INSTITUTE p 9 pP p unvented gas log set.To reduce the risk of by professionals who are certified in the U.S. combustion of such fuels,contain chemicals known fire or injury,do not install an unvented gas by the National Fireplace Institute"(NFI)as to the State of California to cause cancer,birth de- log set into this fireplace. 0 NFI Woodbuming Specialists or who are fects and other reproductive harm. certified in Canada by Q California Health&Safety Code Sec.25249.6 Wood Energy Technical �&Rvr CERTIFIED r.�nMmr nw�m• ,,,,,,,a,,,,Mba•Training(VJETT). --••• D• Not Discard for 30004671 3/11 R-4 2 30004671 Merrimack Large Insert Merrimack Large Insert Specifications Installation Installing the Merrimack Large Insert into an existing Merrimack Large Insert masonry fireplace is an effective way to add an efficient o Toro' EPA Emissions Rating .3.6 hr "Under specific test conditions used during EPA emis- heater to your home.The existing fireplace and chim- ...................................... g/ P 9 z'Min. Range of heat output`..............10,750-31,780 BTU/hr sions standard testing. ney must meet certain requirements. Min .o To 1e' Maximum heat output".........................55,000 BTU/hr —This value can vary depending on how the unit is Requirements . • Fireplaces 2'Min.3, Area heated"...................................up to 2,000 sq.fl. operated,and the type and moisture content of the fuel Min. Size of wood splits..........................up to 22"(560 mm) used.The figure shown is based on maximum fuel con- The Merrimack Large Insert is listed for installation Fuel Capacity..........................................40 lbs.(18 kg) sumption obtained under laboratory conditions and with within a properly built masonry or heat circulating,ma- Loading..................................................................Front average efficiencies. sonry-type fireplace that is constructed in accordance Flue size....................................................6"(150 mm) —These values are based on operation in buildin _ with the requirements of recognized building codes.A Fireplace Insert weight.......................480 lbs.(218 kg) g heat-circulating masonry-type fireplace must conform Reverence Ac617 code conforming homes under typical winter climate to building code standards for masonry fireplaces,and Primary Air Control............................................Manual conditions in New England.If your home is of nonstan- Fi 2 The 2'-T-10'rule for chimneys. Glass panel..........................High-temperature ceramic dard construction(e.g.unusually well insulated,not in- must consist of a factory-built metal firebox with air g Flue exit position......................................................Top sulated,built under ground,etc.)or if you live in a more circulation pathways that are surrounded by masonry Do not connect your Merrimack Large insert to a Blower rating...............................150 cfm.(115V,60Hz) severe or more temperate climate,these figures may materials.Air circulation pathways must not be blocked chimney flue serving another appliance. Power Cord Length...................6 foot useable installed not apply.Since so many variables affect performance, by the insert or surround panels. consult your Vermont Castings'Authorized Dealer to The fireplace and chimney must be clean and structur- determine realistic expectations for your home, ally sound.Have them inspected by a qualified profes- In the U.S.(ANSI/NFPA 211,1988),when sional chimney sweep,a mason,or your Vemlont Cast- installed in a masonry fireplace: 291i§"(740 mm) ings'Authorized Dealer before the Merrimack Large A connector must extend from the flue collar Insert is installed.Any deterioration(cracks,loose mortar or loose bricks)must be repaired. to the flue liner. I�24%"(629 mm) The cross sectional area of the flue must be less Codes may permit removal of the damper in order to than or equal to three times the area of the flue make a positive vent connection between the firebox ® and the chimney.However,the fireplace should not be collar.If larger,the chimney must be re-lined. modified in any way without first checking with your lo- Means must be provided to prevent room air cal building inspector or fire marshal.Provision should passing to the chimney cavity. 12Y/e" be made to restore the fireplace to its original condition Provision must be made for removal of the (313 mm) if the insert is removed.Do not remove bricks or mortar insert to clean the chimney flue. that may jeopardize the compliance of the fireplace with General o local building codes. 7Y,. The Merrimack Large Insert is not approved for While not required in most jurisdictions in the (183 mm) installation in factory-built fireplaces. U.S.,MHSC strongly recommends that a full stainless steel chimney liner be installed for the ��311-r.W-m) 25W(645 mm) Requirements for • Chimneys insert to the chimney top to increase overall per- Chimney requirements differ for the U.S.and Canada7 formance and to ease and reduce yearly mainte- f- (449 mm) Specifications for each are listed below.Connect the nance. insert to the chimney in accordance with local codes A masonry chimney must be well-constructed and the requirements of the listing agency as specified and must meet minimum code requirements. in this manual. The chimney flue should have a code-aooroved Tliner made of masonry or ore-cast refractory 26/c' les,straight or flexible stainless steel pipe,or a (668 mm) 231Me" poured-in-place liner.An unlined chimney must (605 mm) Chimney height should be no less than 15'(4.5 m) above the hearth and no more than 35'(10.5 m). be relined professionally. The chimney should extend at least 3'(914 mm)above The chimney must have a nominal flue size 8 the highest point where it passes through a roof,and at 6"2152 mm)diameter or 3 t square inches 5 E31 llm�] least 2'(610 mm)higher than any portion of a building square but no greater than 3 times larger larger r t within 10'(3 m).(Fig.2) square inches(548 crn) A chimney larger than this must be re-lined. Fig.1 Merrimack Large Insert dimensions. 30004671 3 4 30004671 Merrimack Large Insert Merrimack Large Insert Be aware that a chimney originally designed for fire- A permanent metal warning label must be affixed A place use may perform differently when used to vent an to the back of the fireplace stating the fireplace air-controlled appliance such as your Merrimack Large may have been altered to accommodate the in- B Insert-even if the flue is less than 3 times larger than sert,and may be unsafe to use as a conventional rEthe flue collar.For exam le,a Chimne on an outside rt __®�P Y fireplace.(A Fireplace Modification Tag is in- ®®�wall may not heat up enough to sustain an adequate cluded in the hardware bag inside the Merrimack ®®=draft.Such a flue can often be improved I it is relined to Lar a Insert. ■�9 ) HI• ereduce its size and/or insulated to keep it wanner ■�A ositive flue connection must be made between D,J ceP • ' re ■®the Insert and the first masonry file or prefabri- The Merrimack Large Insert will ft many fireplaces.To C ■cated metal chimney section.A positive flue con- EII_confine that it will fit yours,measure the lintel depth, ■ vection consists of a plate that seals or replaces C FP1085 the fireplace damper and a section of chimney Plus the height,width,and depth s your fireplace and x connector that passes through the plate into the hearth.Compare them to the measurements in the ac- -- -- Fireplace Clearances companying chart. If you choose to install anew hearth A.Mantel` 43" It 092 mm) chimney. over an existing fireplace hearth,be sure to take its Fireplace Minimums FP1084 B.Top Trim(1112") 41" (1041 mm) • The chimney connector must be a minimum thickness into consideration when measuring both front A.width at Face 29Y." (756 mm) C.Side Trim** 22Y4" (578 mm) equivalent to a 6"(152 mm)diameter opening and back height of the fireplace and clearances to any B.Width at Dimension'C' 25" (635 mm) •Clearance shown is for 12"(305 mm)deep mantel.Dimension and must be 24 gauge or heavier stainless steel. existing trims and mantels. C.Depth' 181h" (470 mm) may be reduced to 41'(1041 mm)lithe mantel is 8"(203 mm) D.Height at Face 233/" (603 mm) deep or less. Chimney Connection systems are available from a NOTE: The clearance between the Merrimack Large E.Height at Dimension'C' 233W' (603 mm) "Where side trim extends more than 1 W(38 mm)from the fire- variety of manufacturers.Your Vermont Castings dealer Insert and the mantel,top trim and side trim cannot be Fireplace Maximums place facing,the side clearance must be no less than 31'/."(794 can recommend a system that will best meet the re- reduced by installing shields. H.Lintel depth 9" (229 mm) mm);this is also the required side wall clearance. quirements of your particular Installation. Measure the side clearance(C)from the exact center of your fire- Anotherrequirement to consider is the clearance for I.Width' 45" (1143 mm) place opening on the hearth(X).Measure the top trim(B)and/or movable items such as tables,bookcases,rugs,furnish- J.Height' 32" (813 mm) mantel clearances(A)from the finished hearth surface.Measure ings,and your woodbox. All combustible materials of 1.The minimum depth must be maintained from the floor of the fireplace the front clearance(to furnishings,etc.)from the fireplace face. The chimneymust be sealed off from room air, this type should be a minimum of 48" 1220 mm from to a height of 21'/,"(540 mm) YP ( ) 2.Though the Merrimack Large Insert will fit into larger fireplaces,the Fig.4 Observe these clearances to combustible trim. either by a plate at the damper level or by sealing the front surface of the Merrimack Large Insert. Be sure decorative optional MHSC Surround Panels will not completely cover the the fireplace opening. that family members are aware of this requirement as fireplace opening if these dimensions are exceeded.Custom made trim Unused openings to the flue must be sealed with well,so they too will keep objects a safe distance from I pieces may be used. masonry to the thickness of the chimney wall. the stove. Fig.3 Use these measurements to confirm that the Merrimack The hearth for the Merrimack insert must be construct- Openings sealed with pie plates or wallpaper are Large Insert will fit into your masonry fireplace. ed over a completely noncombustible surface(such as a hazard.In the event of a chimney fire,flames unpainted concrete over earth).This noncombustible and smoke may be forced from the openings. Clearance Requirements i hearth must extend at least 16"(406 mm)in front of the After confirming that your fireplace is the right size, doors as protection from heat radiated from the insert. check the clearance to combustibles.First mark with This means the noncombustible hearth must extend In Canada(CAN/CSA-8365-Mg1,Section 5): tape the exact center of your fireplace opening on the 23"in front of the fireplace face opening in a typical A full chimney liner meeting ULC S635,Class III hearth.Measure the side clearance from this point. installation. (stainless steel)must be installed from the insert Measure the top trim and/or mantel clearances from the In addition,spark and ember protection is needed 8" to the chimney top,and securely attached to finished hearth surface.Measure the front clearance(to (203 mm)to each side of the insert and in Canada, both.The damper may be removed to accommo- furnishings,etc.)from the fireplace face.(Fig.4) 18"in front of the insert.The approved construction of date the liner. _ Hearth -., this protection is a minimum or 24 gauge galvanized • The opening of the fireplace around the insert sheet metal or equivalent.Figure 5 shows the details of must be sealed to prevent room air passing to the In some fireplaces,the hearth in front of the fireplace hearth requirements. fireplace cavity. opening is brick,stone,slate,or some other non-com- • Existing air-circulation chambers in a fireplace bustible material that is in direct contact with concrete with a steel liner may not be blocked. poured over earth. These are the only hearths that are • Provision must be made for removal of the insert considered noncombustible.In other fireplaces,the to clean the chimney flue. brick or concrete hearth in front of the fireplace opening is supported by heavy wooden framing.Because nei- • The existing fireplace damper(if any)should be ther brick nor concrete has good insulating properties, locked in the open position. heat radiated by the fire will pass downward through the hearth to the wooden framing. Such hearths are considered combustible. 30004671 5 6 30004671 Merrimack Large Insert Merrimack Large Insert 3. If the overall R-value of the system is greater than Fristalling the Merrimack Large Insert the R-value of the specified floor protector,the alter- ®' nate is acceptable. 1. Remove emovet isable thee damper.Fireplace anyla mperscDamper.lfcodes al- EXAMPLE:The specified floor protector should be 1'h- low,remove moving damper.Mer pin a dlorcan t removed Flexible Flue Liner inch thick material with k-factor of 0.84.The proposed simply by removing a cotter pin and/or a set screw. alternate is 4"brick with an r-factor of 0.2 over 1/4" If it is not permissible or possible to remove the damper, secure the damper in the fully open position. Flex Liner Adapter mineral board with a k-factor of 0.29 p Step a:Use formula above to convert specification to -NOTE:CANADIAN INSTALLATIONS- (if required) 1 1 R-value: R In accordance with CAN/CSA B365-M91, you must ° =-xT=— x1.5=1.79 7" k 0.84 permanently secure the Fireplace Modification Tag to Adjustable(26"or verti- ° • I B•(178 mm) Step b:Calculate R of proposed system, the rear of the fireplace cavity if you have modified the cal)Flue Collar vdlnte- B 4°brick of r=0.2,therefore: /fireplace in any way to accommodate installation of a grated Draw-Doom Bar A Rb-=0.2 x 4=0.6 fireplace insert.This tag is in the hardware bag included Top of the Insert Around Step c:1/8"mineral board of k=0.29,therefore with your Insert. Flue opening I~ C Rmme._= 1 X025-0.86. 2. Flue collar orientation:The flue collar maybe oriented washers 1/4 Dia. — 029 in the vertical position or rotated 180 degrees on the top 1/4-20 Hex Nuts ST1002 Step d: Ra•=Rbb°w+Rm__=0.8+0.86=1.66 of the stove resulting in a 26 degree backward angle.If United states Canada Step e:Compare proposed system Rtotal of 1.66 to possible,determine beforehand which orientation will Fig.6 Components of the venting system. A. 18- (460 mm) 18" (460 mm) specified R of 1.79.Since proposed system Rtotal is work best for your application. _ B. e" (203 mm) 8" (203 mm) C. 46'h" (1181 mm) 461/z" (1181181 mm) less than required,the system is not acceptable. In most applications,cleaning of the chimney system will In all cases,the hearth must be completely noncombustible in front Definitions be easiest from the top(chimney cap)down.If this is the of the insert to the dimensions shown.The hearth must also be planned method for your application,the center iron pull Mantel - IWthickwith k-factor of 0.64. R=(ft')(hf)(°F) k= (Btu)(in) =Kx 12 down handle on the flue collar serves as protection to In the US,if the insert is elevated 21k"(64 mm)or more,no Cher- �� (t tr F) prevent a chimney brush from damaging the baffle inside ef.26" mal or ember protection is necessary beyond 16"(406 mm). i the stove.If cleaning can only take lace from inside the FP7ler K= (Btu)(ft) r=(ff)(hr)(°F)= 1 9 Y P Fig.5 Unless your fireplace and hearth are constructed over (ft')(hr)(°F) (Btu)(in) k home,the center bar may be cut out of the flue collar using a dirt floor(or unpainted concrete over dirt),you must use a a hack saw or reciprocating metal cutting saw. floor protector that satisfies the above requirements. 3. Install the venting system:Again,depending on your 20W application it may be easiest to install the connector or Access (521 mm) • • •• Optional • • stainless steel Flue liner in the chimney first. Refer to Door Protection Materials are AcceptableCustom-made surround panels may be made from any Figure 6 for the components of the venting system. noncombustible material. Possible All floor protection must be noncombustible(i.e.met- • Carefully remove the fiber baffle by first removing Handle Bracket - - als,brick,stone,mineral fiber boards,etc.).Any organic MHSC offers a steel or cast iron surround panel kit. the front airwash manifold.If necessary,remove the Locations ST2493 materials(i.e.plastics,wood paper products,etc.)are air tubes to allow easier access. Fig.7 Measured height from the finished hearth surface to combustible and must not be used.The floor protection Remove the iron flue collar from the stove and fasten the center bar of the flue collar. specified includes some form of thermal designation either the adapter pipe or flue liner to it by drilling the cover plate and insert the provided grommet into such as R-value(thermal resistance)or k-factor(ther- three holes using the holes in the iron collar as a the slot.Reattach the cover plate. mal conductivity). guide. S. Install Mantel andAccess Door.Remove the prepack- Procedure: Secure the flexible pipe to the pipe adaptor using aged mantel and install the two(2)brackets to under- 1. Convert specifications to R-value: the same method. side of mantel using four(4)1/4-20 Philips head black i. R-value given-no conversion needed. Install the connector pipe or liner so that the height screws as shown in Figure 8.Brackets and screws can ii. k-factor is given with a required thickness(T)in measured from the finished hearth surface to the be found in the hardware bag located inside the unit. inches: R=!x T center bar of the flue collar is 201k"(521 mm).(Fig. Unwrap the two(2)pre-assembled access doors and k 7)This will allow an easy connection once the stove snap into place.If the spacing between the doors and iii.K-factor is given with a required thickness(T)in is rolled into place. upper lattice is not even,you can pull the doors mantel inches: R= 1 x T 4. Route the blower ower cord.Run the ower cord off and adjust the upper lattice.Screw the two 2 jack- iv. P P 1 PP O1 iv.r-factor is given with a required thickness(T)in out the left or right side of the insert.Remove the two ing screws that contact the front up or down as needed. inches: R=r x T (2)louvre doors(Fig.9)or access doors.Remove the (Fig.9) 2. Determine the R-value of the proposed alternate screw and washer from each side holding the ashlip 6. Install the Optional Surround Kit.Follow the instruc- floor protector: to the front.If you run the power cord out the left side, tions provided with the kit. i. Use the formula in Step 1 to convert values not remove the two(2)screws holding the rheostat bracket 7. Roll the Firebox into Position.At least two people will expressed as R. to the fan housing.Insert grommet nearest fan in the slot be needed to move the firebox.To ease installation,lift ii. For multiple layers,add R-values of each layer to on the fan housing,left or right side.Reattach rheostat the front of the stove slightly to put weight on the rear determine overall R-value. bracket with the two(2)screws removed earlier.Remove wheels.Position the firebox so the flue collar aligns with 30004671 7 8 30004671 Merrimack Large Insert Merrimack Large Insert Replace the stainless steel air tubes,if removed, To complement the manual setting of the air control,the This feature is primarily intended for reloading the stove Bracket and by sliding them first to the right and then into the Merrimack Large Insert has an integral convection air when lower air settings(low heat output)are desired,but .Awn screws Bracket and blower that ensures an even delivery of heat at the manual it is also useful any time the firebox is too cool for proper Screws mating holes on the left.Secure these in place with setting you select. combustion or when freshly added wood does not ignite the stainless steel cotter pins. readily. • Before installing the airwash manifold,replace the - For maximum efficiency and performance,the Merrimack fiber baffle board and ensure it slides all the way The convection fan delivers a steady stream of warm air insert should always have visible flames in newly added ,., S to theand an the ire should idesof ht fitLove.between the into the room.Use the fan speed control to regulatetheflow wood,either within the fuel pile or near the roof of the board and the iron sides of the stove. of air into the room.Athermal switch will automatically de- firebox.Wood moisture,piece size,draft,weather and • Replace the front air tube and secure it in place with activate the fan when the stove cools down.When starting firebox temperature will all have an effect on how quickly Fig.8 Secure bracket to mantel with two(2)Philips screws. the cotter pin. a fire in a cold stove,this switch will typically energize the flaming occurs.The automatic setback air control is a the connector.Use the leveling screws at the front of 9. Connect the Blower power cord to the power sup- fan within about 20 minutes,after the stove heats up. convenient feature allowing more user flexibility and ease the Insert to adjust the level. Route the power cord to ply.DO NOT ROUTE THE POWER CORD UNDER the side nearest the power supply. OR IN FRONT OF THE UNIT. The fan speed should set "lora'(fully closed)when of operation. operating at low to medium burn rn rates and may be set � High-Quality 8. Connect the Flue Collar.: From inside the stove, 10.lnstall the supplied handle storage bracket by simply anywhere between"low"and"high"when operating athigh Burn reach up and pull the flue collar into place by lining up sliding the flat end under the right or left side of the burn rates.(Refer to Figure 11 for fan access) The Merrimack Large Insert is designed to burn natural the two 1/4"studs in the stove top. Care should be stove.(Fig.7) wood only; do not burn fuels other than that for which it taken to not disturb the gasket which seals the collar This completes installation of your Merrimack Large was designed. to the top. Tighten the two 1/4"nuts. Insert. You'll enjoy the best results when burning wood that has been adequately air-dried. Avoid burning"green"wood that has not been properly seasoned or cordwood that is Operation more than two years old. The best hardwood fuels include oak,maple,beech,ash, • • • • Primary Air Controland hickory that has been split,stacked,and air-dried All Merrimack Large Insert controls are conveniently lo- A single air control regulates the amount of heat the fire outside under cover for at least one to two years. cated on the front.(Fig.9) will produce and how long it will bum. For areas that do not have a supply of hardwood,com- Three controls regulate the performance ofyour Merrimack The primary aircontrol lever is located on the upper left monly burned softwoods include tamarack,yellow pine, Large Insert: side on the front of the insert.The lever regulates air for white pine,Eastern red cedar,fir,and redwood. These The primary air control supplies oxygen for the fire. starting,maintaining,and reviving the fire. too should be properly dried. The variable-speed fan control,or rheostat,regulates Generally,more air entering the stove makes the fire bum Your Merrimack Large Insert will accept wood up to 22" the warm air flow into the room. hotter and faster,while less air prolongs the burn. I speed Control (559 mm).Longer wood pieces work better than short An automatic setback control provides a high air setting The Merrimack Large Insert's air supply is increased when open Bottom Louvre to ones. of restarting or reviving a fire after reloading and closes the control lever is moved to the left,and decreased when Access Fan controls ST1156 Wood should be stored under cover to maintain dryness. automatically once the stove reaches operating tempera- moved to the right. It may be set anywhere between the Fig.11 Fan control access. Even for short-term storage,however,keep wood a safe two extremes,depending on the amount of heat desired. distance from the heater and keep it out of the areas tures. (Fig 10) , Setback • • around the heater used for re-fueling and ash removal. Space Between Doors and Upper Air Control The automatic setback air control is used when starting or Use the Air Control Settings Air control Lever Lattice Lever open- reviving afire and provides an increased flow ofoombustion that WorkBest for You Leverto the Left air to the fire until the firebox is sufficiently heated.This air supply automatically resets to the desired air setting, No single aircontrol setting will fit every situation.Settings Jacking taking the guesswork out of operating the stove. for each installation will differ depending on the quality of Screws t the fuel,the amount of heat desired,and how long you •••••••••••••••• •••••••••••••••• Jacking Figure 9 shows the automatic setback control.Move the wish the fire to burn. •'••••••••••••'• ••••'••••••••••• screws primary air control lever all the way to the left.Push the primary Control about one more inch to the left to open the The control setting also depends on your particular"draft," Closed- air shutter(the lever will spring back automatically when or the force that moves air from the stove up through the Control Lever to the Right released).The shutter will remain open only if the stove chimney.Draft is affected by such things as the length, is below its proper operating temperature.Once open,the type,and location of the chimney,weather,local geogra- primary air control lever may be adjusted to any desired phy,nearby obstructions,and other factors. position.Once the stove heats up to its proper operating Too much draft may cause excessive temperatures in the temperature,you will here a clicking sound confirming the Merrimack Large Insert,and could even damage internal Fan Speed control Behind louvre FP2493 ST1157 shutter has closed.This returns the stove to the output components.On the other hand,too little draft can cause Fig.9 Merrimack Large Insert controls. Fig.10 The air control lever controls the amount of air enter- setting of the primary air control. backpuffing into the room or a very sluggish fire. ing the firebox. 30004671 9 10 30004671 Merrimack Large Insert Merrimack Large Insert How do you know I your draft is excessively high or low? Follow these guidelines as you start and maintain the 4. Once a good ember bed of at least 3-4"(76-102 mm) bed is less than 2-3"(51-76 mm),activate the automatic Symptoms of too much draft include an uncontrollable fire,and remove the ashes.Prior to starting a fire with a hasformed,add the desired amountofwood and close setback feature.This will provide extra air to start the fire burn or glowing-red cast iron.A sign of inadequate draft is cold stove,it is recommended to clear the lower primary the primaryaircontrol to medium-low setting.The fire flaming and'setback'to the desired air setting once the smoke leaking into the room through the stove or chimney air hole located at the nose of the front brick.To do this, volume will diminish immediately,but the Merrimack stove is heated. connector joints,low heat,and dirty glass. remove the andiron and lift out the front refractory brick. Large Insert will continue to heat up.Maintain control Finally,adjust the air control and fan speed for your de- In some newer homes that are well-insulated and weather- Sweep any ash accumulation out of the air slot.Keeping of the fire using the primary air control,and remember: sired heat level. tight,poor draft may result from insufficient air in the this slot clear of ash will ensure better performance. reduce the setting for less heat,increase the setting NOTE: If the charcoal bed is relatively thick and your fuel house.In such instances,an open window near the stove 1. Open the primary air control fully. for more heat. Refer to the air control settings chart is well-seasoned,it is possible to add fresh fuel(smaller on the windward side of the house will provide the fresh 2 Lay several sheets of crumpled newspaper in the on Page 10 for recommended settings at different bum pieces first),close the door,and reset the air control im- air needed. rates. bottom.Place on the paper six or eight pieces of dry, mediately. When first using the stove,keep track of the settings of finely-split kindling.On the kindling lay two or three Do not over-Tire this heater. the air controls.You will quickly find that a specific setting larger sticks of split dry wood approximately 1-2"(25- Overfiring may cause a house fire,orcan result in per Special Tactics for Cold-Climate Heating - will give you a fixed amount of heat. It may take a week 50 mm). manent damage to the stove.If an exterior part of the The Merrimack Large Insert is capable of producing up to or two to determine the amount of heat and the length of Do Merrimack Large Insert glows,you are overfiring. 55,000 Btu/hour and heating an area of up to 2,000 sq.ft. burn you should expect from various settings. bun garb ge or chemicals ids to startthes gase.Donot _ However,man factors affect heating performance and burn garbage or flammable fluids such as gasoline, Reloading Wood Y g Most installations do not require a large amount of com- naptha,or engine oil. Also,never use gasoline-type can influence the extent to which the Merrimack Large bustion air,especially if adequate draft is available. Do lantern fuel,kerosene,charcoal lighterfluid,orsimilar Set the air control on"High,"and wait at least fifteen sec- Insert can heat a given area. not for any reason attempt to increase the firing of liquids to start or'freshen up"a fire in this heater. onds for the draft to increase.Turn the convection blower A well-insulated home,located in a moderate climate and your heater by altering the air control adjustment Keep all such liquids well away from the heater while off.Open the doors slowly. with the Merrimack Large Insert located centrally in an range outlined in these directions. it is in use. IMPORTANT:While the stove is hot,toss and sift the open floor plan,will be easier to heat than a drafty home in Use the following primary air control lever and fan speed 3. Light the newspaper and close the door. Gradually coals with each stove loading.This loosens and helps the far north in which a Merrimack Large Insert is installed control lever settings as a starting point to help determine build up the fire by adding a few 3-5" (76-127 mm) burn coals that become buried in the ash.Push coals on an exterior wall at the end of a long house. the best settings for your installation. diameter splits. away from the bottom airjet.Creating this"void"helps In Fireplace Insert installations,over-sized chimneys can maintain a reliable fire. produce less effective results than those that are properly Merrimack Large Insert ControlIf this is your initial break-in fire,let the fire burn brightly, Check the ash level,and remove excess ash.A primary sized,and interior chimneys usually perform better than but not to excess.Control the fire's intensity by adjusting air hole located under the front brick provides air to the those located outside the house. Primary Air Air Circulation the air control lever.After an hour or so stop adding wood Bum Control Fan Control so that the fire dies out gradually. coal bed.(Fig.12)This hole should be cleared of ash for Different results may be experienced even in the same Rate Setting Speed Position proper performance. installation if you switch from burning good,dry wood to For ongoing operation after the initial break-in,continue wood that is partially rotted or inadequately seasoned. High Fully left High Horizontal to add a few sticks at a time of a progressively larger size. To compensate for these factors in cold climates,it may Medium 1"from Low Turn clockwise Be sure to keep the fuel load behind the front grate bar Primary Air be necessary to operate the Merrimack Large Insert for full right at all times. Continue until you have a live ember bed at Hole Low Fully right Oft Tum counterclockwise least 311"(76-102 mm)deep.This may take an hour or longer periods of time with the air control set to a higher longer,particularly when the Merrimack Large Insert is level more of the time. Starting • Maintaining a Wood Fire vented to an exterior masonry chimney or when you are Remo -and Store Burn solid wood fuel onlylust starting a fie. �In the Merrimack Large 9 In- Check the ash level before reloading the stove,remove sert,and bum it directly on the grate. Do not elevate You'll soon find that the insert is HOT WHILE IN OPERA- ashes I necessary.Tum off the fan before shoveling the the fuel. Do not bum coal or other fuels. TIONI KEEP CHILDREN,CLOTHING,AND FURNITURE AWAY. CONTACT MAY CAUSE SKIN BURNS. ash into your ash container. Cast iron is a superior material for solid fuel stoves but Remove ash regularly,typically every one to three days. it must be treated with respect. It is extremely strong, NOTE: Some chimneys need to be"primed,"or warmed The frequency will vary depending on how you operate your but can be broken with a sharp blow from a hammer or up,before they will draw sufficiently to start a fire.To cor- Merrimack Large Insert;more wood is consumed at higher from the thermal shock of rapid and extreme temperature rect this situation,roll up a couple pieces of newspaper, lace them on to of the kindling and toward the back of heat output settings,and ash will accumulate faster. changes.It is important to temper the cast iron plates with P P 9 sT++sa Mdiron Ash should be removed frequently and placed outdoors in a an initial series of 3-4 break-in fires. The plates expand the stove,light them,and close the doors.This should Fig.12 Keep primary air holes free of ash for proper perfor- metal container with a tight-fitting lid.The closed container and contract with changes in temperature. Minimize heat the chimney enough to initiate a draft. mance. on thermal stress by allowing the plates to adjust gradually Once the draft is established,open thefront doorand light of ash should placed on ll non-combustible floor during the break-in fres by following Steps 1-3 on the the rest of the fuel from the bottom.Do not light the main Add the fuel,smaller pieces first. If it necessary to use the ground,wellll away from all combustible materials,pend- during wood smaller than the 18"(460 mm)optimum size,be ing final disposal.If the ash is disposed of by burial in soil following page. bed of fuel until the chimney begins drawing,and repeat sure to fill the firebox as completely as possible by load- or otherwise locally dispersed,it should be retained in the WARNING:Operate your Merrimack Large Insert only the procedure as often as necessary I the initial attempt ing the wood pieces alternately on the left and right.Split dosed container until all cinders have thoroughly cooled. with the door fully closed. If the door is left partially is unsuccessful. wood will fill the firebox more completely and reduce the Wood ash may be used as a garden fertilizer. open,gas and flame may be drawn out ofthe fireplace frequency of reloading.If possible,stack wood diagonally CAUTION: Never use your household or shop vacuum opening,creating risks of both fire and smoke. to maximize air spaces between fired pieces. cleaner to remove ash from the fireplace;always remove If you have an ember bed of at least 2-3"(51-76 mm), and dispose of the ash properly. the air setting may not need to be adjusted. If the ember 30004671 11 12 30004671 i i �� Merrimack Large Insert Merrimack Large Insert Maintenance IMPORTANT NOTES Examine the gasket that seals the glass to the door frame.If necessary,replace this with gasket ob- Do not operate the Merrimack Large Insert if the tained from your local Vermont Castings'authorized • • Adjust '• Periodically glass is damaged or broken. dealer. Directions for replacing gaskets are given Looking New and The front door of the Merrimack Large Insert should Do not abuse glass by striking with any object or belo Working w. Care close securely to prevent accidental opening and by slamming the door. Check the channel at the bottom of the door frame, of •n Surface should close tightly to prevent air from leaking into the Replace glass only with MHSC high tempera- and clear away debris if necessary. An occasional dusting with a dry rag will keep the fire chamber.The door handle will be positioned verti- ture ceramic glass,available from your Vermont Carefully place the new glass in the door frame. painted cast iron of your Merrimack Large Insert looking cally when the door is closed. Castings'authorized dealer. Secure the clips,being careful not to over-tighten. new. Over a period of time,the gasket around the door will Be sure the glass is firmly seated against the gasket. If the paint needs retouching,first allow the surface to compress and the latch may need adjustment. To ad- AWAR N I N G Close the door gently to confirm the clips have been cool completely.Mask glass,trim parts and enamelled just the handle,follow this procedure: properly positioned.It is possible for the glass to be areas.Wire-brush those areas to be painted. Touch-up 1 Remove and retain the lock nut with a 9/16"wrench. HOT GLASS WILL damaged if the clips have been installed incorrectly (Fig.13) CAUSE BURNS with high temperature stove paint available from your . and the door is closed with force. local dealer.Apply the paint sparingly.Two light coats are better than one heavy one. 2. Loosen the set screw with a 1/8"Allen wrench. DO NOT TOUCH GLASS How to Replace Gaskets 3. Rotate the pawl 180•.Replace the lock nut.Tighten Fit UNTIL COOLED. Care • •• the set screw. NEVER ALLOW CHILDREN Your Merrimack Large Insert uses rope-type fiberglass Use a soft brush as necessary.Do not use water or 4. Additional adjustment can be made by removing the TO TOUCH GLASS. gaskets to make a tight seal between some parts. With other liquids on your Merrimack Large Insert.Finger- Flat washer.Or any combination of washer removal use,particularly on those parts that move,gaskets can prints usually can be buffed off porcelain enamel with and/or pawl rotation. Removing Replacing ••r Glass become brittle and compressed and can begin to lose a dry,soft cloth.If marks remain,allow the Merrimack their effectiveness. These will need periodic replace- Large Insert to cool completely,then buff with a slightly Roller Follow this procedure to replace glass, ment. dam soft cloth.D completely before starting a fire toJN.t der Screw All of the gaskets used are made of fiberglass. The P. Dry P Y 9 Open the door and loosen the four retaining clip 9 9 avoid streaking. screws that hold the glass to the door.Swing the three sizes of replaceable gasket are listed below,along Never use abrasives or harsh chemical cleaners on clips out of the way.Tilt the glass away from the door with their application. the porcelain enamel finish;the enamel may scratch frame and lift up.(Fig.14)Wear gloves and use cau- Replaceable Merrimack Large Insert and expose the cast iron,which can then stain or tion when handling broken glass. Fiberglass Gaskets rust. If you must remove spills or stains from porcelain surfaces,make sure the fire is out and the Merrimack Gasket Size...................And The Parts It Seals Large Insert has cooled completely before cleaning. 3/8"(1203564)...............Door to the front-5.6' 3/8"(30002422).............Firebox parts Use a kitchen appliance cleaner and/or polish specifi- Loc3/16"(1203556).............Glass to the door-5.2' cally formulated for enamel surfaces. Apply the cleaner sparingly with a soft cloth,and buff away all traces. } To changea gasket,wait until the fire is out and the Flat Washer J stove has cooled.Wear protective eyewear and a dust Cleaning the GlassHandle Stub ST1154 mask.The procedure is the same for all gaskets. 1. Remove the existing fiberglass gasket by grasping The Merrimack Large Insert glass system requires a Fig.13 Rotate pawl and/or remove gat washer to adjust d an end and pulling firmly minimum amount of cleaning.Most carbon deposits latch. that accumulate will bum off during hot fires. 2. Use a wire brush or the tip of a screwdriver to clean Test the door seal.Close the door on a dollar bill and the channel of an remainingcement,silicone or bits Ash residue that accumulates on the glass should be attempt to pull it free.If the bill is freed with little re- of asket, y removed periodically to prevent etching.To clean the sistance,the gasket isn't snug enough at that spot. Retainer g glass,use the following procedure. Continue to make small adjustments until the setting is clips 3. Apply c thin bead of high temperature silicone the newly-cleaned groove.A 1/8!'-3/16"bead is suf-f- • Be sure the glass is completely cool. right. ficient. Cleaning with water will work in most cases. Use If additional adjusting of the latch does not enable the 4. Place a new gasket into the groove.Wait until you a glass cleaner especially made for this purpose door to seal sufficiently in one area,try"adjusting"the have placed all but a couple inches from the end only if deposits are specially heavy. (If heavy gasket in that area.Pack more cement or a smaller before you trim the end to an exact fit. deposits are a frequent occurrence,however, diameter gasket into the channel beneath the gasket so evaluate your operating techniques.) Do not use the main gasket is raised and makes contact with the abrasive cleaners. door frame.If this procedure doesn't solve the problem, Q • Rinse the glass thoroughly. replace the gasket.Instructions for gasket replacement Door • Dry the glass completely. are given later in this section. Gasket Glass Fig.14 Replace glass. Glass Panel Gasket ST1155 30004671 13 14 30004671 �� Merrimack Large Insert Merrimack Large Insert Replacing light,sight up through the flue collar into the chimney Yearly Spring Cleaning: theDoor flue.The fiber baffle will need to be removed gently to view inside the connector pipe. Remove ash from the firebox and replace with a For parts and information about your insert,contact • Remove the door by lifting it straight up from its moisture-absorbing material(such as kitty litter) your Vermont Castings authorized dealer.For the name hinge pins. If it is necessary to remove the firechamber to inspect to keep the interior of the stove dry. of the dealer nearest you,contact: • Lay it face down on a padded surface. or clean the chimney,this is how to do it: Touch up painted surfaces with black paint. MHSC Remove the glass. Follow the instructions for re- Let the Merrimack Large Insert cool. 149 Cleveland Drive moving and replacing glass which start on Page Disconnect the fan power cord. Flex Connection: Paris,KY 40361 14. You may wish to lighten the firebox by removing Two Months: 800-668-5323 Replace gaskets.Follow steps 1A,above. the load door and andiron. Inspect the chimney and flue connection.Clean • Replace the glass. Retract the two levelling screws until they bear no the system if necessary. • Replace the door. weight. Yearly Spring Cleaning: The Chimney System • Remove the front air tube and fiber baffle. Disassemble the flue connection and take it In the event of component failure,it is very important to A Clean Chimney System is Safer • Disconnect the flue collar or vent connector from replace with equipment equivalent to the Vermont Cast- the top of the stove. outdoors for inspection and cleaning.Replace ings original parts. weak sections of connector. ' WorksSlide the firechamber forward until you have ac- Inspect the chimney for signs of deterioration. Although the non-catalytic combustion system in your cess to the fireplace opening. Repairs to a masonry chimney should be made Merrimack Large Insert can reduce creosote formation Inspect the flue. by a professional mason.Replace damaged dramatically,it is not a substitute for regular inspection You can now inspect the smoke shelf area of the fire- sections of prefabricated chimney.Your local and cleaning of the chimney and chimney connector, place and the chimney.Before replacing the Merrimack Vermont Castings'dealer or a chimney sweep Large Insert,this area should be inspected for signs of can help determine when replacement is Learn toRecognizedeterioration and cleaned thoroughly with a chimney necessary. And • '—Creosote brush. • Thoroughly clean the chimney. Your Merrimack Large Insert has been designed to Clean the chimney using a specially designed brush the minimize creosote build-up.Regular chimney inspection same size and shape as the flue liner.Flexible fiber- and maintenance,however,must still be performed. glass rods are used to run the brush up and down the Optional Accessories For safety,good stove performance,and to protect your liner,causing any deposits to fall to the bottom of the chimney and chimney connector,inspect your chimney chimney where they can be removed through the clean- and chimney connector on a regular schedule. Clean out door. Northfield Cast Iron Surround the system if necessary. Failure to keep the chimney The chimney connector should be cleaned by discon- Model Color and connector system clean can result in a serious necting the sections,taking them outside,and removing NORCSCB Classic Black chimney fire. any deposits with a stiff wire brush. NORCSEB Ebony When wood is burned slowly,it produces tar,organic Reinstall the connector sections after cleaning,being Exeter Steel Surround, vapors and moisture which combine to form creosote. sure to secure the individual sections with sheet metal Model Color a The creosote vapors condense in the relatively cool screws. EXSSCB Classic black chimney flue of a slow-burning fire. As a result,creo- sote residue accumulates on the flue lining. When If you can't do the chimney inspection yourself,con- Imo—461/-4'(1170-) -I 457M'(1165 mm) tact your local Vermont Castings'Authorized Dealer,or ignited,this creosote makes an extremely hot fire within the flue system that can damage the chimney and engage a professional chimney sweep to perform the overheat adjacent combustible material. If a significant inspection and cleaning of the chimney. layer of creosote has accumulated—1/8"(3 mm)or Reverse the procedure to re-install the firechamber. more—it should be removed to reduce the risk of a _ chimney fire. '• ' 32/ 3231,e (817 mm) If you do experience a chimney fire,act promptly to: Fireplace: (818 mm) Close the primary air control lever(fully to the Daily: right). Ash should be removed before the level reaches Get everyone out of the house. the top edge of the front brick.Check each time • Call the Fire Department from a nearby house. you re-load,or at least once a day. You should inspect the system every two months during Keep the area around the fireplace clear of any the heating season as part of a regular maintenance combustible material. schedule. To inspect the chimney,let the Merrimack Northfield Cast Iron Surround Exeter Steel Surround Large Insert cool completely. Then,using a strong 30004671 15 16 30004671 Merrimack Large Insert Merrimack Large Insert Merrimack Large Insert (continued) 6 164 12 Ref. Description Part Number Ref. Description Part Number 4 43 52 27. Insulation,Int.End 30004649 55. Glass,Right(IR coated) 30004654 s12. 28. Insulation,Ext.End 30004648 56. Glass,Left(IR coated) 30004655 z4 40 29. Brick,Back 30004641 57. Glass Clip 30004957 $� ze 17 30. Brick,Right End 30004645 58. Gasket Fiberglass 3/8 low D 6nd 1203589 _� 73 z3 3 59. Gasket Fiberglass 3/16 4nd Blk 1203556 79 5 s347 46 s3 31. Brick,Left End 30004646 39 37 70 v J 48 32. Brick,Bottom Low 30004642 60. Trs Hd PH 10-24 x 1/2-Z 1200998 42 15 33. Brick,Bottom Slnt 30004643 61, Front Steel Hdl/Shaft-BNI-VER 30002717 60 57 34. Brick,Bottom Upper Right 30004644 62. Nut Hex Jam 3/8-16 TOPLK-Z 1203290 /4.�9 I ss 59 54 35. Brick,Bottom Upper Left 30004955 63. Pawl Assy Roller 30005157 -, 36. Brick,Bottom Center 30004956 64. Handle Damper,Maple wood blk 1600664 zs s Ilii 37. Tube A,Secondary Air 30004377 65. Pan Hd SL 1/4-20x3-Z 1201310 30 27t 1 38. Bt30004647 66. Insert Lifter Handle 1600650 • m� 10 14 39. Bottom Assy 30004662 67. Fallaway Handle Bracket 30005048 4 26 2 71 � 54 40. Right Side Shld,2nd Air 30004396 68. Nut Acorn 1/4-20-Z 1203118 25 13 74 41. Left Side Shld,2nd Air 30004404 69. Ss soc 1/4-20x1 1/4 Cup Pt-SS 1200414 32 1 s1� 1s60 � 61 /< 42. Shroud,Outer 30004665 70. Cotter Pin,1/8"x1' "L-SS 30004405 7 to 34 7a1 t Sj 56a s.f}-� 43. Top Shroud 30004660 71. Insulation,Bottom 30004650 I1� `83 _ 44. Flange,Flue Collar Surround 30004675 72. Insulation,BHS 30004402 21 41 36 a5s 45. Cover,Power Cord 30004379 73. Friction Spring 1201846 33 20 35 46. Automatic Air Setback Assy 30004999 74. Bracket,Access Door 30004949 2s ss�'f 3t e s 47. Bracket,Mantel 30004679 75. Bushing(bottom door hinge brckt) 30005225 68 27 a 48. Front Hinge,TR/BL 30004945 49. Front Hinge,TL/BR 30004950 72 39 541-; 49. 50. Disk 30005050 7 51. Throttle Lever 30005051 52. Spring 30005052 MHSC reserves the right to make changes in design,materials,specifications,prices and discontinue colors and products at any time,wthout 53. Bracket,Upper Lattice 30004676 notice. 54. Bracket,Door Hinge 30004947 Merrimack Large Insert Shell Enamel Parts-Merrimack LarcieInsert Part Name Classic Black Ebony Ref. Description Part Number Ref. Description Part Number Door Left 30004626 30005193 1. Bottom 30004620 17. Mantel Refer to Enamel Chart Door Right 30004627 30005194 2. Back 30004621 18. Air Cover Plate 30004640 Door,Access 30004630 30005195 3. End,Right 30004622 19. Collar,Flue 30004317 Ashlip 30004636 30005196 4. End,Left 30004623 20. Fan Kit Assy 30004669 Lattice,Front,Top 30004637 30005197 5. Top 30004624 20a. Replacement Blower Only 30004412 Lattice,Front,Bottom 30004638 30005198 6. Front 30004625 20b. Snapstat Wire Assy. 30004406 Mantel 30004639 30005199 7. Door,Left Refer to Enamel Chart 20c. Rheostat and Wire Assy. 30004407 Side Panel,Left 30004634 30005200 8. Door Right Refer to Enamel Chart 20d. Power Cord 1601482 Side Panel,Right 30004673 30005201 9. Base Plate 30004628 20e. Snapstat 30005236 10. Air Manifold 30004629 20f. D Knob 1604419 11. Door,Access Refer to Enamel Chart 21. Side Panel,Left Refer to Enamel Chart 12. Cover Plate,Top 30004631 22. Side Panel,Right Refer to Enamel Chart 13. Andiron 30004635 23. Airplate 30004315 14. Ashlip Refer to Enamel Chart 24. Pinion 30004320 15. Lattice Front,Top Refer to Enamel Chart 25. Wheel 30004319 16. Lattice Front,Bottom Refer to Enamel Chart 26. Shaft,Wheel 30004318 30004671 17 18 30004671 LIMITED LIFETIME Warranty For Vermont Castings Merrimack, Non-Catalytic Large Insert Limited Lifetime Warranty MHSC warrants that all refractory brick and mate- 5. Damage to the unit while in transit is not covered rial used in this product will be warranted against by this warranty but is subject to a claim against the deterioration not resulting from Physical damage or common carrier.Contact Vermont Castings Autho- overioading of the woodstove for the lifetime of this rized Dealer from whom you purchased your stove or Product.This coverage includes the components of MHSC if the purchase was direct. (Do not operate the EverBurn System:"shoe,fountain,and fireback. the stove as this may negate the ability to process the Coverage is Provided only to the original Purchaser. claim with the carrier). Limited 3 Year Warranty 6. Claims are not valid where the installation does not All cast iron parts are warranted for a period of three conform to local building and fire codes or,in their ab- years against breakage,cracking or burn-through. sence,to the recommendations in our Owners Guide. 7. The salt air environment of coastal areas,or a high- Limited 1 Year Warranty humidity environment,can be corrosive to the porce- The following part of the woodburning stove are war- Iain enamel finish.These conditions can cause rusting ranted to be free of defects in material and workmanship of the cast iron beneath the porcelain enamel finish, for a period of one year from the date you receive it: The which will cause the porcelain enamel finish to Flake handles,glass door panels,door gasketing and porcelain off. This warranty does not cover damage caused by finish.Any of these items found to be defective will be a salt air or high-humidity environment. repaired or replaced at no charge,upon the return of the 8. MHSC shall have no obligation to enhance or update part with postage prepaid to a Vermont Castings Autho- any unit once manufactured. rized Dealer. IN NO EVENT SHALL MHSC BE LIABLE FOR INCIDENTAL Any parts repaired or replaced during the limited warranty AND CONSEQUENTIAL DAMAGES.ALL IMPLIED WAR- period will be warranted under the terms of the limited RANTIES,INCLUDING THE IMPLIED WARRANTIES OF warranty for a period not to exceed the remaining term of MERCHANTABILITY AND FITNESS,ARE LIMITED TO THE the original limited warranty or six(6)months,whichever DURATION OF THIS WRITTEN WARRANTY. THIS WAR- is longer. RANTY SUPERCEDES ALL OTHER ORAL OR WRITTEN WARRANTIES. Exclusions&Limitations Some states do not allow the exclusion or limitations of 1. This warranty is non-transferable. incidental and consequential damages or limitations on 2. This warranty does not cover misuse of the stove. how long an implied warranty lasts,so the above limi- Misuse includes overfiring,which will result if the stove tations may not apply to you.This warranty gives you is used in such a manner as to cause one or more specific rights and you may have other rights,which vary of the plates to glow red.Overfring can be identified from state to state. later by warped plates and areas where the paint pig- mentsHow has burned off.Overfiring in enamel stoves is identified by bubbling,cracking,chipping and discolor- If a defect is noted within the warranty period,the cus- ation of the porcelain enamel finish.MHSC offers no tomer should contact a Vermont Castings Authorized warranty on chipping of enamel surfaces.Inspect your Dealer or MHSC'If the purchase was direct with the fol- woodburning stove prior to accepting it for any dam- lowing information: age to the enamel. 1. Name,address,and telephone number of the pur- 3. This warranty does not cover misuse of the stove as chaser described in the Owners Guide,nor does it cover a 2. Date of Purchase. stove which has been modified unless authorized by 3. Serial number from the label on the back a MHSC representative in writing.This warranty does 4. Nature of the defect or damage. not cover damage to the stove caused by burning salt 5. Any relevant information or circumstances,e.g.,instal- saturated wood,chemically treated wood,or any fuel lation,mode of operation when defect was noted. not recommended in the Owners Guide. A warranty claim will then start in process.MHSC re- 4. This warranty does not cover a stove repaired by serves the right to withhold final approval of a warranty someone other than a Vermont Castings Authorized Dealer. claim pending a visual inspection of the defect by autho- rized representatives. MHSC 149 Cleveland Drive•Pans,Kentucky 40361 vww.mhsc- 30004671 19 From:Patricia Maker Fax: To: 9786889542@rcfax.con Fax: +19786889542 Page 2 of 2 11/16/2015 4:20 PM ,acoR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/16/2015 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 policy(ies) must 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 such endorsement(s). PRODUCER CONTANAME: Judith George CIC,CPIA,CPIW FIAI/Cross Insurance PHONE (603)669-3218 FAC No); (603)695-9331 1100 Elm Street EMAIL eor a@crossa enc ADDRESS:�g g agency. cam INSURER(S)AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURERAAcadia Insurance Group, LLC 31325 INSURED INSURERB:Safety National Casualty CO MIS BEC OF NH, INC. DBA THE STOVE SHOPPE INSURERC: THE COMMONS INSURER D: 25 INDIAN ROCK ROAD ROUTE 111 INSURER E: WINDHAM NH 03087 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 All- Stove Shoppe 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. NOTWITHSTANDING 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. INSR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMIDDNYYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE-'CRENTED- X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence $ 250,000 A CLAIMS-MADE I—XI OCCUR CPA0311123-15 /1/2015 /1/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO, X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED CAA0311124-15 /1/2015 /1/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERX HIRED AUTOS X AUTOS NON-OWNED (P r.ccident AMAGE $ AUTOS Uninsured motorist properly $ 25,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A4EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ CUA0311125-15 /1/2015 /1/2016 $ B WORKERS COMPENSATION To be issued directly by WC STATU- OTI-N AND EMPLOYERS'LIABILITY Y/N TORY IMI S ER ANY PROPRIETOR/PARTNER/EXECUTIVE carrier E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (MandatoryinNH) (3a.) MA & CT /1/2015 /1/2016 E.L.DISEASE-EA EMPLOYE $ Ifyyes describe under 1officers included DESdRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule, I'more space is required) Job: Brian O'Donnell - Bear Hill Road Certificate Holder is included as additional insured with respects to the CGL as per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Andover MA Town Offices 36 Bartlett St. AUTHORIZED REPRESENTATIVE Andover, MA 01810 J George CIC,CPIA,CPI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSf125 vminnr%m Tk-Art-%Dr)..e.,,e—4 I--- —;-+—.d— -..f Arr1Dr1 A ® DATE(MM/DD CERTIFICATE OF LIABILITY INSURANCE 12/31/2014014 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to t,% -ms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the c, tate holder in lieu of such endorsement(s). PRODUCER CONTACT Judith George CIC,CPIA,CPIW NAME: g FIAI/Cross Insurance PHONE (603)669-3218 IC No:(603)645-4331 1100 Elm Street E-MAIL eor a@crossa en com E-MAIL ADDRESS: g g ' INSURERS AFFORDING COVERAGE NAIC q Manchester NH 03101 INSURERAAcadia Insurance Group, LLC 31325 INSURED Fences Unlimited Inc INSURERB:Granite State WC Manufacturer's Mis-Bec of NH, Inc. dba The Stove Shoppe INSURER C: The Cormnons INSURER D: 25 INDIAN ROCK ROAD ROUTE 111 INSURER E: WINDHAM NH 03087 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 All- NH WC 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. NOTWITHSTANDING 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 250 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ r A CLAIMS-MADE a OCCUR PA0311123-15 1/1/2015 /1/2016 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO JECT X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 0311124-15 /1/2015 /1/2016 BODILY INJURY(Per accident) $ AUTOS X,AUTOS X NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Uninsured motorist property $ 25 000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ UA0311125-15 /1/2015 /1/2016 $ B WORKERS COMPENSATION C012014000032 X WC STATIM US TS O R AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N (3a.) NH E.L.EACH ACCIDENT $ 1_0.00,000 OFFICER/MEMBEREXCLUDED? N/A 1 officers included 1/1/2015 1/1/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ l"000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 i . l DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. l ` aml" z AUTHORIZED REPRESENTATIVE J George CIC,CPIA,CPI '� �`-' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025lgninnS1n1 Thn A(`r)Rr1 namn and Innn am rnnicfnrarl marlrc of errnRn ✓�ie -Pom7mwncu - - ea,/,f./z a�.-/�aaaac�iva�,lta _ Office of Consumer Affairs&Business Regulation i v HOME IMPROVEMENT CONTRACTOR 3 I Registration:,-,�"'F54.473 Type: e` Expiration 3114/2w Private Corporatior1 MIS BEC OF N.HJINC ��' rd f KEN SZYMANSKY 25 INDIAN ROCKRDSUITE.1 9 WINDHAM, NH 03087 Undersecretary Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-096606 KEN T SZYMANSY ` :'• , 271TCKLEFANCY SALEM NH 0301-9If �41A Expiration Commissioner 02/25/2016 i r'' The Commonwealth of Massachusetts f Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA.021.14-.2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERN.IITTING AUTHORITY. Applicant Information Please Print Legib NaMe(Business/Organization/Individnal): Address: t.(3` 9d 03')& City/State/Zip: Phone#: cs 3 Are you an employer?Check the appropriate box: Type of project(required): ltK4_am a employer with�mployees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F1 Building addition 4.F]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.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14dKOther idl4l Lt a34 4WO 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] w . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors 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-cor&actors have employees,`they must provide their workers'comp.policy number. I am an employer that is pioviding workers'compensation insurance for my employees.•Below is the policy and job site information. Insurance Company Name: C Policy#or Self-ins.Lie.#: G I DL OJ y O O UCb.3 _ Expiration Date: Job Site Address: �" ` I'J�P/� �� City/State/Zip: 4 Q�T 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 st ent ay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern u der e pain d p alties ofperftay that the information provided above is true and correct. Si nature: Date: 6 Phone#: d 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#: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. A ' .1 Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract o,,f hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or"permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you*are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-in'sur6d companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"fob Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia