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DEPARTMENT OF BUILDIXG INSPECTIONS 8
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
SOLID FUEL BURNING APPLIANCE & CHIMNEY APPLICATION PERMIT NUMBER � +
�7 Page r Plot _s_s2� Zone
Location }�l�d✓i"� 5 '� a D� ��°�° rY7n� �
Owner or Lessee
c�� LI A/ C • a r
(Name) Mailing Address Tele. No.
Contractor '/,/, / '_ 6 , l-arclr� 101110_/
(Name) (Address) (Tele. No. )
RESIDENTIAL NON-RESIDENTIAL
L/ One 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
Manufacturer
Purchased From
(Name of Firm)
(Address)
Cost - Construction & Appliance $
6V .
Chimney New Metal Bestos
-- Existing Interior chimney
Separate Flue Exterior chimney
i,4_ Other appliance attached to flue
--V Masonary Lined
Unlined
Notes & Data:
Signature of Applicant:
9 (Address)
C.
Approved By: {y
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Title: Date: �_
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