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esVten n�.� Applicant on for a Permit to Build No. 1
UPON FINAL APPROVAL .. ' 2 Q � O MAP sa LOT � ��
FEE MUST ACCOMPANY THIS APPLICATION. DATE NOIR 19 GT(�
The undersigned hereby applies fora permit to build /f/ c3/q'2'
according to the following specification
1. Name of property owner ' ' Tel Tel ?qy o.7 5-0
Address TA 'OIC &# SovfN/�i,Z) rim 1afr /J?A
2.Name of Architect(if any) Tel.
3. Name of builder . /W0/1l2. — --- Address
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.
7. Construction address - 'flt?( I nyktoK R62 So vrIl �jnct 70/1N
Flood / District
8. Date of subdivision proval plain zone Zone
9. Private dwelling Estimated Cost DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 `�i 00 in "Zceu.L knnn /
11. Commercial 0 Kitchen
12. Other 0 /0p� Dining Rm.
13. No. of stories WM vl Living Rm.
Bed Rm.
14. Foundation — Full i% Half 0 Crawl 0 Slab ❑ Bath
15. Materials — Wood 0 Cement 0 Other 0 Deck
16.Type of heat i
it ❑ Gas 0 Electric 0 Other 0 Closed porch
17.Garage — 1 ❑ Family Rm.
Sun room
18. Swimming pool - Size Garage
19. Stora
�� shed —7 e - IShed
0."5tove Wood Coal 0 IN p oa (gyp 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 deann� � /..��
Mit citx..
PLANNING BOARD Address / fly ,/
Date 20 p/ln-..4iJ/,h 439 0016611
WOOD STOVE INSTALLATION CHECKLIST
Permit
A buildirog permit is required for the installation of any solid fuel burning appliance. The building permit.and 54°i4istallation inspection are limited to the stove installation and not to the ve construction. ,g
Stove lino 49 stave- P 681
A. NewUsed
B. Type/radiant — Circulating
C. Manufacturer ' Lab.No.
Name/Model No. £FITC I✓ RprYS Coilarsize 't /I
Dimensions/Height /3 ' Length ay/ Width /ar ••
Chimney ,
A. New Existing VVV
B. Size(flue area)
C. Other appliances attached to flue(Number and flue size)
D. Prefab(Manufacturer—name and type) •
E. Masonry/Lined Flue liner
Unlined (type 8 manutac:unr)
F. Height(refertodiagrams) cap
. 1
I CVER Id I I ovER Id I _ 112't MIN.
I •
�2 MIN. 2 Mit ,
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S MK ,o, IG' " 3 NIH. 11— -,X
1 .
I. _ IL"IN.
M
I CI
18"MIN.
�- FUEL/ASH
--- `— , Acce7;#t
og. HEARTH
•
CHIMNEY HEIGHT
Hearth(non-comoustlbl
A. Materials SL E Oil FLQa& . OiAzk e/?/fr> .
B. Sup-floor construction
C. Minimum andWaons(refer todiagram) �)1 �! //J/�
Clearances and Wall Protection isee stove i st Ilan n clearances chart)
A. Type of wail protection crowned a 5ritriLI
B. Clearances(refer to diagrams)
(.. _
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TrY�I£ 1vv� /��N
i r` • rs T
t
. FIREPLACE CORNER WALL/CENTER
•
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