16A-020 (5) City of Northampton
A Massachusetts
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1/.� DEPARTMENT OF BUILDING INSPECTIONS li
212 Main Street • Municipal Building ,;
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Northampton, MA 01060
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SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION T M A'qe °Ns
FOR WOOD,COAL, PELLET, CORN,STRAW OR SIMILAR STOVES,OR FIREPLACES
Check#
Please fill in all appropriate information
1. Name of Applicant : 2 u A te.C (�_�}Y1 LA)a t/
Address: . Q ' i 4 A)/"4 < / � (���'� Telephone: q 13 3 4f 6-3
2. Owner of Property : _ ��n
Address: Telephone:
3. Status of Applicant : Owner _ Contractor
4. Type or Brand of Stove
5. Estimated Cost :
If applicant is not the homeowner::
Contractor name
Construction Supervisor's License Number Expiration Date
Home Improvement Contractor Registration Number Expiration Date
All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit
6. Certification: I hearby certify that the information contained herein is true and accurate to the best of my
knowledge.
DATE: APPLICANT'S SIGNATURE
DATE: I ( �2-C� I ( HOMEOWNER'S SIGNATURE kal_ C�
APPROVED
DATE: BUILDING OFFICIAL
608 FAIRWAY VLG BP-2016-0918
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-020 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2016-0918
Project# JS-2016-001558
Est. Cost: $5000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: CONWAY SALLY
Zoning: URA(102)/WP(17)/WSP(15)/ Applicant: CONWAY SALLY
AT. 608 FAIRWAY VLG
Applicant Address: Phone: Insurance:
608 FAIRWAY VILLAGE (413) 582-0230 ()
LEEDSMA01053 ISSUED ON.112012016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL JOTUL PELLET STOVE
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 1/20/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner