17A-078 (8) City of Northampton
-�' Massachusetts
ECE� DEPARTMENT OF BUILDING INSPECTIONS �.
12 Main Street • Municipal Building
r Northampton, MA 01060
t
OCT 3 p
2019
7� 79
o
DFPT OF FUILDIN
NORTHAh1P7pC I"PECTIONS
I WO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION
FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACES
Check# I_:_3 v
-� Please fill in all appropriate information
1. Name of Applicant : a!f,(\ mo' I i n o w-SK)
Address: '3 0 r oxn /cn A Oore6 c e Telephone: Y1 3
2. Owner of Property : �� /►�-�2/ (i
Address: 30 C arra !,n Telephone:
3. Status of Applicant Owner Contractor
4. Type or Brand of Stove : cU cm qlj h1 -e
OL
5. UL Listing : S 0 �1 1 3
6. Estimated Cost : '000
7. Email : R-2 C. 1 h 6 toad
If applicant is not the homeowner::
Contractor name Email
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
8. Certification: I hearby certify that the information contained herein is true and accurate to the best of my
knowledge.
DATE: l CJ���& APPLICANT'S SIGNATUREt.�----
DATE: 4x669 HOMEOWNER'S SIGNATURE
APPROVED
DATE: f obo6q BUILDING OFFICIAL .TW