38-062 (7) PERMIT QI IL
VALIDATION
DATE �19 PE IT NO.
APPLICANT ADDRESS
(NO.) (STREET) (CONTR'S LICENSE)
NUMBER OF
PERMIT TO (_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
ZONING
AT (LOCATION) DISTRICT
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT_ BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: 'zav d-4�
AREA OR � D PERMIT
VOLUME ESTIMATED COST FEE
U81C/SQUARE FEW
OWNER lo
BUILD) G DE
ADDRESS BY
WHITE - FILE COPY GREEN - FIELD COPY ■ CANARY - APPLICANT COPY • PINK - ASSESSORS COPY
'* { of Vort4a ptan
# � �assaci�usetts _
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
1NSPECTOf2 Northampton, Mass. 01060
PERMIT NUMBER
SOLID FUEL BURNING APPLIANCE b CHIMNEY APPLICATION �----
Page 39'A Plot 2— Zone
Location 0
No��f Street
Owner or t -(�ttiC�$r,,A�12 XG�v�✓ O Eo,, ` (G -CO t 7
Lessee {Name} Mailing Address} Tel. No.)
Contractor
Name Address Tel. No.
RESIDENTIAL NONRESIDENTIAL
One Family Home Business
Two or More Other
Number of Units Specify
Type of Appliance ^�,�
New >
_.. 1 good Burning
_ Used Coal
Labeled Combination
Date of Purchase Other
Specify
Model or Type
Manufacturer
Purchased From 1 p
Name of F
Address
Cost - Construction & Appliance $
Chimney New Existing
Separate Flue Other Appliance Attached
To Flue
Masonary/Lined Metal Bestos
Masonary/Unlined
Exterior Interior
Notes & Data:
1
Signature of Applicant: (bc)
r Address
Approved By: /
Title Da