32C-029 test
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 Check #__________
PLEASE TYPE OR PRINT ALL INFORMATION
PROPERTY ADDRESS_______________________________________________________________________________
Name of Applicant:______________________________________________________________________________
Address: __________________________________________________Telephone:___________________________
Owner of Property:______________________________________________________________________________
Address: __________________________________________________Telephone:___________________________
Status of Applicant: ____Owner ____Contractor
Type or Brand of Stove:____________________________________________________________________________
Contractor’s Name: ____________________________________________________________________________________
Contractor’s Address: ___________________________________________________________________________________
Contractor’s Phone: ____________________________________________________________________________________
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
Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: __________________ APPLICANT’S SIGNATURE__________________________________
DATE: __________________ HOMEOWNER’S SIGNATURE_________________________________
APPROVED
DATE: __________________ BUILDING OFFICIAL ________________________________________