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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 2:12 Alain Street " iNfunicii�al Building
Northamptoji, Alass. 01060 4' S"
SOLID FUEL, BURNING APPLIANCE & CHIMNEY APPLICATION PERMIT NUMBER
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Page III o t: Zone
Location ��U ./ (� I'C>C�It >_l r ✓` -
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Owner or Lessen
(Name:) (Malllng Address) (Tale. No. )
Contractor
(Nar ) (Address) (Tele. No. )
RESIDENTIAL NON-RESIDENTIAL
One family Home Business
Two or More Other
Number of Unitas Specify
Stories in Building
Type of Appliance
New /' Wood burning
Used Coal
Labeled Combination
Date of Purchase Other
V Specify
Model or Type
Manufacturer
Purchased From
(Name of Firm)
_ti , C1'YC
(AddressT,
Cost - Construction, & Appliance: $
Chimney /New Metal Bestos
Existing Interior chimney
Separate Flue Exterior chimney
Other Appliance attached to flue
Masonary Lined
Unlined
Notes & Data:
Signature of Applicant-: �i� ;, -a t. / , I, ar°
(Address)
Approved By.
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Title. _ _� Date: 0 l
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