12-022 (3) 11/17/2014 12:45 14137334130 THREE RIVERS PROGRAM PAGE 02/02
C
f Northampton
NOV I 1 ?01 lassachusetts
cfric'. Building
-,--212-jM1ir1 Stme t • Xufticipal h. off
�Cfio ztbampton, MA 01060
n
SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET,CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS
Permit Fee: $25.00 Chieck# Wf lf
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 12a�,zt- "ba e-e bkc-k
Address; 6Z,,j-k-k 4,, L(.j �—J-—/ ��Telephone:
2, Owner of Property:
Address, 2-0 C-' r-,e e v, Abe, Pr Flarlhc..e- Telephone:
3. Status of Applicant L--(SNner Contractor
4, Type or Brand of Stove: &24)+
If applicant is not the homeowner:
Construction Supervisor's License Number Expiration Dot
Home Improvement Contractor Registration Number Expiration Date
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
5. Certification.I hereby certify that the Information contained herein Is true and accurate to the beat
of my knowledge.
DATE; APPLICANT'S SIGNATURE
DATE: j f7 HOMEOWNER'S SIGNATURE
APPROVED
DATE: BUILDING OFFICIAL
47 3 ((
31 COUNTRY WAY BP-2015-0577
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12-022 CITY OF NORTHAMPTON
Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2015-0577
Project# JS-2015-001099
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19994.04 Owner: CHABOT ROBERT&FRANCES HACK
zonine: Applicant: CHABOT ROBERT & FRANCES HACK
AT. 31 COUNTRY WAY
Applicant Address: Phone: Insurance:
20 GREENLEAF DR (413) 584-3494 (�
FLORENCEMA01062 ISSUED ON.1111812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 11/18/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner