23D-160 City of Northampton _
Massachusetts :1^"' "0`
µ'l15,1 DEPARTMENT OF BUILDING INSPECTIONS ° r
212 Main Street • Municipal Building ��o
Northampton, MA 01060 s °°^ 1
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 #
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS t `�I L 0 1A-06-0 /-----4` de
1. Name of Applicant: /(f f-.� NS i 7 / J EI L 414 - A �� t �[
Address: 1 ct i/ /" ` �Jl Telephone: q-(3 - 3 -7' -----).3/ 5/
O
2. Owner of Property: ` -k l i "! / I /`.. 1 7 (
Address: S G ' 5 : ' Telephone: 1- 1 f 8 3C 2_
3. Status of Applicant: v Owner Contractor ' t\-s i
4. Type or Brand of Stove:
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 IrkersCompensation Insurance Affidavit before we can issue - a pernrit
5. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
/
DATE: APPLICANT'S SIGNATURE
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
147 MAPLEWOOD TER BP- 2012 -0936
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 160 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- 2012 -0936
Project # JS- 2012 - 001630
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 20952.36 Owner: FITZGERALD ALWYN L & ANGELA E TRUST
Zoning: URB(100)/ Applicant: FITZGERALD ALWYN L & ANGELA E TRUST
AT: 147 MAPLEWOOD TER
Applicant Address: Phone: Insurance:
202 NATCHEZ TRACE
MADISONWI53705 ISSUED ON:4/26/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL WOODSTOVE
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 4/26/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Ali: