29-222 (5) City-of Northampton
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" OCTDEP NT OF BUILDING INSPECTIONS
(i '6 2014 21 Street • Municipal Building �tc-., a
orthampton, MA 01060
EleCtriN Plumbing&Gas Inspections
Northampto�Q106^ 0
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# 1#G
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 2"122:,111r"11�fr'� G �'�/✓�" 7c�Q
Address: / CSl�e �� _Telephone: l�� 3 I/ /C'
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner �Contractor �, p
4. Type or Brand of Stove:
If applicant is not the homeowner:
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: j 6 APPLICANT'S SIGNATURE T/ fzL-11 zL `k/? /(-) 177 !
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
120 ACREBROOK DR BP-2015-0396
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-222 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-2015-0396
Project# JS-2015-000715
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: ROLDAN FRANCISCO M&NELLY E
Zoning: Applicant: ROLDAN FRANCISCO M & NELLY E
AT: 120 ACREBROOK DR
Applicant Address: Phone: Insurance:
120 ACREBROOK DR
FLORENCEMA01062 ISSUED ON.101712014 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 10/7/2014 0:00:00 $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner