35-086 City of Northampton
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Massachusetts
r *: 4 t �i ( ' D PAR NT OF BUILDING INSPECTIONS,r'
ro 12 =in Street • Municipal Building <.
Northampton, MA 01060 j \
DEPT. OF BUILDING NSFECTIONS
NORTHAMPTON MA 01060
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check # /56 q
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS �n tP
1. Name of Applicant: l.l� dZi�iZLV-00S/(/
Address: 5' 9 7 J BQe, r Telephone: JOT V 4 0 6
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contractor
4. Type or Brand of Stove: C-9/77A/77/ F
Contractor's Name:
Contractor's Address:
Contractor's Phone:
Construction Supervisor's License Number: Expiration Date:
Home Improvement Contractor Registration Number: Expiration Date:
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: APPLICANT'S SIGNATURE
2 7 -
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DATE: HOMEOWNER'S SIGNAT / � - -��� "�/ _ alth)
APPROVED
DATE: BUILDING OFFICIAL
56 WESTWOOD TER BP- 2013 -0637
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 086 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP-2013-0637
Project # JS- 2013 - 001038
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10759.32 Owner: SZAWLOWSKI JEROME J & SUSAN M
Zoning: Applicant: SZAWLOWSKI JEROME J & SUSAN M
AT: 56 WESTWOOD TER
Applicant Address: Phone: Insurance:
56 WESTWOOD TER (413) 584 -4668 ()
FLORENCE ,MA01062 ISSUED ON:12/10/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: SANTA FE PELLET STOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/10/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner