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:� ,... % Application for a Permit to Build No. h 1 V
UPON FINAL APPROVAL irk MAP f7 LOT j. 67
FEE MUST ACCOMPANY THIS APPLICATION. DATE 1o//7/ 19 90
The undersigned hereby applies for a permit to build //,-/9V
according to the following specifica ions
1. Name of property owner �S, fi, Tel. 79t Oa q-a
Address /3 " 4r 7d 04,+-+
2.Name of Architect(if any) Tel.
3. Name of builder kettA.J Address
4. License No. Tel.
5. Name of Mason Address
6. License No. //Tel.
7.Construction address / 3/4 r v) a--c . 7�L�
8. Date of subdivision Approval , _ plain zone O District
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
10. Multi family ❑ /A 070,®Z7 Type of room No.
11.Commercial 0 Kitchen
12. Other 0 Dining Rm.
13. No. of stories '�p?0,� 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 Rm.
Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size - Shed
20. Stove — Wood lZ Coal 111-7-4../..) 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 9L4c ..e. '1
PLANNING BOARD Address /3� J� we--
Date rt_
WOOD STOVE INSTALLATION CHECKLIST
C./. 1... " /1 ?A
Permit
A bfii(ding hermit 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 a^tigenc.---• Used
B. Type/radiant / Circulating
A
C. Manufacturer I • n,. Lao.No.
Name/Model No. '' ' - Collar size 6 //
Dimensions/Height S �r/9 Length PY0 b Width -2 i-19,1:7
Chimney
A. New Existing 1.7
B. Size(flue area)
C. Other appliances attached to flue(Number and flue size) ikiii
D. Prefab(Manufacturer—name and type)
E. Masonry/Lined Fiue liner eidt
Unlined (type amanutae: tort
F. Height(refer to diagrams) cap
a
I °vsg.lo' I I ouE2 Id I I l2" MIN.
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2 Mit
3'Mil's' }io' IG' 3 MIN. +—*
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CHIMNEY HEIGHTH /
h(nos•com uat1 -O u,- 73 /CI Pi/flair/1a�!
A. Materalsi /. � •
A. Ma /e 74D6' yaY) 73 18rl
B. Sup-floor construction e t te-i .
C. Minimum dimensions(refer to ciacraml
Clearances and Wall Protection isee stove instailaticn clearances cnart) •
A. Type of wall protection proviced
B. Clearances(refer to diagrams)
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FIREPLACE CORNER WALL/CENTER
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