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V,t«Pa.in°41 0- io
Appii� t� n fora Permit to Build No. (0 5 1
UPON FINAL APPROVAL `�l-90
. . .MAP LOT
FEE MUST ACCOMPANY THIS APPLICATION. DATE //// 19 go
The undersigned hereby applies for a permit to build // 7//f/ pc
according to the following specifications
N. Name of property owner -Ro$L/{T C 3 OY{CK ET Tela 3 fe Z-g/Yr
Address .3 '1 &T&s sAJ LAND ri4. YAn o un/PoRT 1 M4 0 2-62 7 .5-
2.Name of Architect(if any) - Tel.
V3. Name of builder Address
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.
Construction address 3f GR.BENLAND 61+2. Y-4tti av1//Pater, ici4 o 24-75-
Flood
-67sFlood . District
8. Date of subdivision Approval plain zone Zone
9. Private dwelling ❑ Estimated Cost , DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 ` %3-00 -,, , /
11. Commercial ❑. / " -) Kitchen
12. Other ❑ _, Dining Rm.
Living Rm.
13. No. of stories
gi .09 Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0
a Bath
15. Materials — Wood ❑ Cement ❑ 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 0 Coal Er4z.r,J 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 */ed -rte ,treA<f "
PLANNING BOARD Address 511 GREOw)'owo eraCCGE
Date Wyk evr//Pa-4T A44 atG 7S
WOOD STOVE INSTALLATION CHECKLIST
—S .-
C./. L ''"
• 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 / Used
A. New
B. Type/radiant vr Circulating
C. Manufacturer t Mr/ Lkz'u 5 e :Na Lab.No. .
Name/Model No. N am/Cacti,' tk I Collar size C. "
Dimensions/Height 23' Length 1-0(/t( t Width LS`/a-" •
Chimney t/
A. New Existing
B. Size(flue area)
C. Other appliances attached to flue(Number and flue size) 0
D. Prefab(Manufacturer—name and type)
E. Masonry/Lined ✓ Flue liner c-tHY
Unlined (type 8 manufacturer)
F. Height(refertodiagrams) cap
. a
I cvc_� lo' I I- OVER t0 I Sr I l2° MIA.
—1— t I qr
3' vtiN Io, IG' " 3 MIN, --*
I - l�
MIN.
/ ^ 1 �. 18"
CFUE/A.4i
0 HEARTH
ei
/70
�,CHIMNEY HEIGHT 6 % 1t' 0
Hearth(non-comoustible7tic/e Wl5Gv� '/ fr erlyie�ia
A. Materials
.
B. Sup-floor construction Fie ere yid 1,4,-6-,0 vac 9t Jj(775,Y.s/a^'
C. Minimum dimensions(reser to ciacraml
Clearances and Wall Protection Isee stove installation clearances cnart) .
A. Type of wall protection provided
S. Clearances(refer to diagrams)
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FIREPLACE CORNER WALL/CENTER
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