29-172 (3) +ii an 1i a r It it 6 V is ^ —
` U131?A1:'1'hIENT OF WAI.DOX.; INSPECTIONS A -
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• 12, 1 ��'
lnin Sh,eot "' XtunicipUl Ituildin ' s
INSPECTOR Nortltaniptory Alrass. O1060
SOLID FUEJ, BURNING APPIJANC:� & (',IIIMNi?Y APPLICATION PERMIT NUMBER
Pnge _ Pl rti" 2otte -ee reVeIrse
Location W [ � ee-,&e-ld
Owner or Lesser rMfCLCkR e.e"j 5n,�
(Name) (Ma1.1 :1'.119 Andreas) (Tele. No. )
Con t rat:.trot•
(Nar-, ) (Add re±ss) (Tele. No. )
RESIDENTIAL NON-RESIDENTIAL
One family Horne. Bttsirxess
Two or More � Other
Number of Units Specify
Stories in P�Zii.l.di.nY
Type of Appl.ianr,e /
7` ,,�e.v I/ Wood burning
—�— Used Coal.
I�(? Labele'd Combination
Date of Purchase _ Other
W/ �.ot;S2 $� Spec 1.fy
Model or 'Type --
M h n u f a c t u r e r
Purchased From "�
(Name of Firm)
(Address) +�
Cost - Canstructi.on & Appl.lance $ Vn<< •
Chimney New Metal Bestos
.Y'- Existing(cmCre-te.) interior chimney
_ Separate Flue, �Ext:erior chimney
Other Appliance attached to fioe
MasonAry Lirtetl
Unlined
Notes & Data:
Signature of Applicant: �i�
(Address)
Approved By:
Title: r Datr,: /�%"
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