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42-142 pEp7,OF BUILDING INSPECTIONg NORzMPTON OINOLE on TWO I AMILY SUE_in FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS Permit Fee: $25.00 Check it t2a PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant eu9/aA L `Abtic'e. Address: S Il a r X61 a 4-16y /)i A Telephone: ``{13 7?3- 0 2_ Owner of Property: /3/a k V)/r)nit I't S" Address: /0 75- G/E'.,7//►i rn a p/p r`) Telephone:. 51/3 .5-37 f L 3. Status of Applicant Owner ,'' Contractor 4_ Type or Brand of Stove: le/MCI Id/ /atu ?t' VC If applicant is not the homeowner: I/ Construction Supervisor's License Number 9'9510/ Expiration Date 7—" Home Improvement Contractor Registration Number /6015a r Expiration Date 7- T- 191 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 best of my knowledge. DATE: /- /� APPLICANT'S SIGNATURE DATE: /v°/I-/-g HOMEOWNER'S SIGNATURE 4-34k- APPROVED DATE: BUILDING OFFICIAL Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1075 WESTHAMPTON RD BP-2013-1223 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42- 142 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2013-1223 Project# JS-2013-002011 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BERNARDSTON FARMERS SUPPLY 99401 Lot Size(sq. ft.): 105850.80 Owner: SIMMONS BLAKE E&LYN M NUTTELMAN Zoning: Applicant: BERNARDSTON FARMERS SUPPLY AT: 1075 WESTHAMPTON RD Applicant Address: Phone: Insurance: 43 RIVER ST (413) 648-9311 () WC BE RNARDSTONMA01337 ISSUED ON:6/19/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL LENNOX WINSTON 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 6/19/2013 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner