12-005 City of Northampton
,� Massachusetts
i DEE'AR NT OF BUILDING INSPECTIONS }} . "'
•< , 212 'n Street • Municipal Building =IA ;,fi
Northampton, MA 01060 s 'Ay �
ag -32013
DEPT. OF BUILDING INSPECTIONS
•RTHAMPTON, MA 01060
SIN e - , 1 • ' Y ' SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Check # 3
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS /67 "Valedi Fj4eois A2,0 dogencG - 0/06„2-.
1. Name of Applicant: �N9ip e. ‘teC..
Address: /6 7 fraG82' .gy is ,2rp / .e,. AjALfelephone: 3 6d 1G Ft, Ceelt
2. Owner of Property: 5#414 4 .
Address: Telephone:
3. Status of Applicant: 4/ Owner Contractor
4. Type or Brand of Stove: pis c Ua C 2. 6/76
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: 1 hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: J 3� �3 APPLICANT'S SIGNATU 4:1!Y/4.1/,�.}K `/'
DATE: HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
167 NORTH FARMS RD B P- 2013 -0684
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12 - 005 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 -0684
Project # JS- 2013- 001132
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 814572.00 Owner: GOLEC JAMES
Zoning: Applicant: GOLEC JAMES
AT: 167 NORTH FARMS RD
Applicant Address: Phone: Insurance:
167 NORTH FARMS RD (413) 362 -9680 0
FLORENCE ,MA01062 ISSUED ON:1/3/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL DISCOVER 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 1/3/2013 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner