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-- o ib ' TOWN OF YA OUTH
e%**---0+ fl Applicattop for a Permit to Build No. 6 / I
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UPON FINAL APPROVAL r ho MAP p LOT .6- �/S
FEE MUST ACCOMPANY THIS APPLICATION. DATE /t/// 19 90
The undersigned hereby applies for a permit to build /0////9()
,pr—ding to the following specifications
1. Name of property owner -1-t....1.. St \ > Tern 5^ Cc5-45L
Address b 1 .� � -C.,-t.
2.Name of Architect(if any) Tel.
3. Name of builder 0-7-()t1-e.- Address
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.e
Construction address to / . J�.rrr.ra, p S 7t./
Flood District
8. Date of subdivision Approval plain zone a Zone
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
gin10.
✓ Type of room No.
10. Multi family 0
11. Commercial 0 Kitchen
12. Other ❑ . Dining Rm.
13. No. of stories Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 Bath
15. Materials — Wood 0 Cement 0 Other 0 Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch
17. Garage — 1 0 2 ❑ Family Am.
Sun room
18. Swimming pool - Size Garage
19. Storage shed — Sizz Shed
20. Stove — WoodIB" Coal ❑ `724-e--1" 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 Signature /. ae V '
PLANNING BOARD Address
Date
WOOD STOVE INSTALLATION CHECKLIST
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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
A. New Used l�
B. Type/radiant Circuiat
C. Manufacturer � ii . -Cs R"r -0 Lao.N . g 1 Zc{ Oe�.
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Name/Model No. �0 t Collar size 7 4
Dimensions/Height a b" Length 3A " Wicth ,_20
Chimney
A. New J4c' "
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Existing
B. Size(flue a) O 1 I
C. Other appliances attached to flue(Number and flue size) • rte,
D. Prefab(Manufacturer—name and type)
E. MasonryiLined J Flue liner J
Unlined pype S manurac:urerI
F. Height(refertodiagrams) 44 4 1 cao T q• '%tn ka Ca,
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z lc' cal' IC IM
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3'kN ',c. tC' j ININ. .a AII�
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1le MIN.
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HEARTH° 1.
CHIMNEY HEIGHT ` V/4/Z913
Hearth(ncn•camcust:ble)
A. Materials e C a.O. t nCp 0
B. Suo•floorconstruc:wn
C. Minimum dimensions(refer to ciacraml
Clearances and Wail Protection Isee stove Installation clearances chart)
A. Type of wad protection provided
B. Clearances(refer to diagrams)
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FIREPLACE CORNER WALL/CENTER
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