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35-115 (9) a x 2�- 13ilv Ali r)tusrtlg " -^ Dlil'Ait'I't�tEN'I' OF BUJLDR,�C; INSPECTIONS - _- INSPECTOR 212 .Xftiin Street " A m'deip<al Building `',� -. =r�,•� Nortli.ampto;.i, A ass. 01060 'Y :301°1.17 FUEL RlHtNINC APPLIANCE, & r1l!lIMNEY APPLICATION PERMIT NUMBER Location fJ r y.�isPi� Ore° Owner or Lessee � � ! o_St'rnQ/Y' I/ l�etl�f �SG� GyL/ S[s✓ °� c�'�. ��/v� (Natnr.) �-Y-� (Mailing Address) (TeLe. No. ) Cont:racl:or° (Na (Tele. No. ) RESIDENTIAL NON-RESIDENTIAL _ One farni.l y Horne. � Business Two or Mora Other Number of ltnit.s Specify Stories 'n Bfiil.ding Type., of Appl.ianne New _ Wood burning Used Coal. • Labeled _ Combination Date of Purchase � Other Spe.c1.fy Model or Type _Res 01'v7-c - Mh.nufacturezr yep. 0 Purchased From la /ry Sow _ (Name of Firm) (Address) aq Cost - Construction & Appliance $ � R Chimney New Metal Bestos Existing Interior chimney r Separate Flue Exterior chimney Other Appliance attached to flue Masonary Lined Unlined Notes & Data: Signature of A ip li a nt.." , ?� ~�JG1/o '_f_i.1i J (Address) Approved By: _ - Title: Date: /l �/ A. fD 'r fD Q y ►+1 N to CA tz) o o n r. C rD n `c A> `� r* CD O fm `< ►` C s* m t7 t� rb tr m 1...1 A• to O C d Ly TJ 2 Cn A. 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