32C-094 (3) r•
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DEPARTMENT OP BUILDIIIG INSPECTIONS °
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
SOLID FUEL BURNING APPLIANCE & CHIMNEY APPLICATION PERMIT NUMBER! �
Page Plot Zone .s-
Location �','Snn A v e t L,.,, -�-o�•
Owner or Lessee la,► v �L
(Name) (Mailing Address) (Tele. No. )
Contractor �
(Name) (Address) (Tele. No. )
RESIDENTIAL NON-RESIDENTIAL
One family Home Business
Two or More Other
Number of Units Specify
Stories in Building
Type of Appliance
New V Wood burning
Used Coal
Labeled Combination .
Oa Ly 6VDate of Purchase Other
Specify
Model or Type V; Qom,' D�
Manufacturer yp.-W
Purchased From
(Name of Firm)
(Address)
Cost - Construction & Appliance $ ?�+ •
Chimney New Metal Bestos
vo" Existing V,- Interior chimney
Separate Flue Exterior chimney
Other appliance attached to flue
✓ Masonary Lined
Unlined
Notes & Data:
Signature of Applicant:- Ui'Sc �41s
(Address)
Approved By:
Title: Date: /K - /�
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