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DEPARTMENT OF BUILDING INSPECTIONS
212 111fiin Street " Municipal Building .......
INSPECTOR Northampton, Afass, 01060
SOLID FUEL BURNING APPLIANCE & CHIMNEY APPLICATION PERMIT NUMBER
Page 9 C1 Pl.oL Zone
Location
Owner or Lessee Qz . C?�
(Na;n
i� (Malling Address) (Tele. No. )
11,
Contractor
(Name) (Address) (Tele. No.)
RESIDENTIAL NON-RESIDENTIAL
--Zone family Home Business
Two or More Other
Number of Units Specify
Stories in Building
Type of Appliance
New Wood burning
_ Used Coal.
Labeled Combination
� Date of Purchase Other
Specify
Model or Type 4;44, r,Vtuvo C
Manufacturer
. At I Lve
Purchased From
(Name of Firm)
(Address)
I
Cost Construction & Appliance
Chimney - w Metal Bestos
Existing Interior chimney
Se parate Flue Exterior chimney
Other appliance attached to flue
MasonAry Lined
Unlined
Notes & Data:
Signature o f Applicant: a.,-1)
(Address)
Approved By:
Title% tr.: