35-269 (4) ,I11 et'415 xrIt It get Is
DEPAK7'IvfENT OF f3(JILD1NC INSPECTIONS
INSPECTOR =x-12 .\'lain Street: . Afwtieipal Building ===7
Northampton, Alass. 01060 4' T
SOLID i Ul:l, BURNING APrLIANCr, & CHIMNrY APPLICATION PERMIT NUMBER
pngr ` Plot. a _ Lone �CtI-,
Location ..._. �- 7—(/.
Owner or Lessor
(Namt ) (Mii.l..i ng Address) (TeIe. No. )
Contractor -
(Nar, ') (Address) (Tele. No. )
RESIDENTIAI. NON-RESIDENTIAL.
Z-' One f nrni.l y Home Business
Two or Mare � Other
Ni.tmber of Units Specify
Stories; in Building
Type of Appl.ianr.e
New Wood burning
_ - Used Coal
I,abeled Combination
Date of Purchase Other
Specify
Mooel or Type
Manufacturer
Purchased From
(Name of Firm) -�
- (Address)
Cost - Construction & Appliance: $
Chimney k'—New PO Metal Bestos
Existing interior chimney
_ Separate Flue Exterior chimney
Other appliance attached to fltiz�
�._ Masonary Lined
Unlined
Notes & Da Ls.
Signature of Appliji ant;
(Address)
Approved By.
Title. Date:
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