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CCit4. .n**M[[5Application for a Permit to Build No. (00O
UPON FINALAPPROVAL ` 1"• MAP 6e LOT )6 °
FEE MUST ACCOMPANY THIS APPLICATION. DATE d - 19 9d
The undersigned hereby applies for a permit to build / 9/9O
according to the following specifications
.N1. Name ofproperty owner Jilcn,o_'o( LT. (-r r1 ,n, ,, Tel. ` 4,6 —/t//y�
Addreselk
s (( ('o ,rec;Ii. &crdn Red. 50.Xf.,n
2.Name of Architect(if any) / Tel.
N3. Name of builder t. u • /s 1 7•A, . ' 'dress Scn--c
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.
—7. Construction address 6/ 1ao ftt c,d &catt fct C. 7YOn toterk
/ Flood ' District
8. Date of subdivision Approval plain zone Zone
. 9. Private dwelling ❑ Estimated Cost DO NOT WRITE IN THIS SPACE
po Type of room No.
10. Multi family ❑ N1 3o0.!
fCDKL
11. Commercial 0 w°O� 0> Kitchen
12. Other 0 CM Or CUS J Dining Rm.
13. No. of stories Living Rm.
Bed Rm.
14. Foundation — Full ❑ Half ❑ Crawl ❑ Slab ❑ It
3M .o Q Bath
15. Materials — Wood 0 Cement 0 Other 0 Deck
16.Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch ,
Family Rm.
17. Garage — 1 0 2 ❑ Sun room
18. Swimming pool - Size ' ' Garage
19. Storage shed - Size Shed .
20. Stove — Wood li'Coal ❑ Alterations
21. Size of lot: No. of feet front No. of feet rear No. of feet deep
' 22. Size of building: No. of feet front No. of feet side - No.of feet rear
23. Distance from nearest building: Front Ft. side Ft. side Rear
24. Distance back from line or street From rear lot line • Side line
LOT RELEASED BY 'N Signature��.•-_�,a74:,„,r,
PLANNING BOARD , • ..Address G/ Ccs/etc, / ,.5-c /2m-C,
Date g n . 7°n rnni/cf7l( i4-ic- .
MOOD STOVE INSTALLATION CHECKLIST bpi�, '94co o~
a
Permit
_ .A_building permit is required for the installation of any solid fuel burning appliance. The building permit and
installation inspection are limited to the stove installation and not to the stove construction.
Stove l` 4
A. New / Used r"p ear ?fLtv
✓
B. Type/radiant Circulating
C. Manufacturer ,_4_.p ea 0 u C k Lab.No. �[ <<
Name/Model No. P ?—S7 Collar size 7-
Dimensions/Height / r Length if " Width /L
Chimney
A. New Existing
B. Size(flue area) 4 if
C. Other appliances attached to flue(Number and flue size) f Al
D. Prefab(Manufacturer—name and type) A?Jt T.wi_ 8 _crdsS
E. Masonry/Lined Flue liner
Unlined (type&manurac:urar)
F. Height(refer to diagrams) cap
cvER to ' ! ovEP le 1 Q�� 112`( Mk
2MIN 1MI �.
smiry o IG' 3 MIN. +-F
I 1 I`'
•
MIN.
I.
1$' MN.
(Ft;i %L
��r t AC..E;.9eft
HEARTH?II
rgo
►TTJJJ
CHIMNEY HEIGHT lib
Hearth(non-ccmoy�tible) r- fL�
A. Materials ( •
B. Sue-floor construction la K C 2! r.0
C. Minimum dimensions(refer to diagram) ''ff
Clearances and Wall Protection(see stove installation clearances chart) 10
A. Type of wall protection proviced y`
B. Clearances(refer to diagrams) �t(�r -n&(
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FIREPLACE CORNER WALLJCENTER •
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