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