36-260 (2) INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirement\ of M.G.L.Cit.112 Ye No❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box elow:
A liability insurance policy V Other type of indemnity ❑ nd ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee dnPc not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waivPsthis requirement.
Check One Only
Owner Agent ❑
Signature of •wner or Owner's Agent
By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation:YES NO
Prngrees IncpPrtions
Date Comments
Final llncrvrtinn,
flat(' Cpmmentc
Type of License:
By ❑Master
Title ❑Master-Restricted
City/Town ❑Joumeyperson Signature of Lice ee
Permit# i.
❑Joumeyperson Restricted License Number:
Fee$ ❑
Check at www macc gnv/dpI
Inspector Signature of Permit Approval
RECEII=® Commonwealth of Massachusetts
E-----1
2013 City Of Northampton
DUI.OF BU, N
�-noN Sheet Metal Permit Permit# 5Y0 -/ 3 `G
NORTHAMPTON MA0 1 __-----.
Estimated Job Cost: $ 625.0D Permit Fee: $
Plans Submitted: YES �jNO X. Plans Reviewed: `YES NO
Business License# 4P/a AC1 Applicant License# -,( ) (70.1q
Business Information: Property Owner/Job Location Information:
Name: At 01 d',w 1 p+i+ Name: 3-.►t. 0 Sd rs tr.
Street: 0 6-QQ 01r S Street: Si �l� gvf a k‘�r/'e,
City/Town:,b IC4 //1 City/Town: Fiarrucit
Telephone: (-ft`7"" ,s--g 9j Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
Staff Initial
J-1/M-1-unrestricted license
J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less
Residential: 1-2 family (./ Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: Renovation: Y\
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
l3at g'xifaysf F4
Fees with Building Permit:$25.00 Residential, $50.00 Commercial.Fees for jobs without a Building Permit$6.00 per$1000
Minimum fees for jobs without Building Permit$50.00 Residential, $100.00 Commercial
File#SM-2013-0062
APPLICANT/CONTACT PERSON DAVID MICHALOWSKI
ADDRESS/PHONE 17 Graves St (413)665-8384
PROPERTY LOCATION 151 MAPLE RIDGE RD
MAP 36 PARCEL 260 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 4g5 sr- ifa c
Fee Paid ��11 0Q JJ
Typeof Construction: BATH FAN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIjMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND/OR Special Permit with Site Plan
Major Project: Site Plan AND/OR Special Permit with Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
ro - m Street Commission Permit DPW Storm Water Management
APA /.h// 3 a -Y
Signature of Building Officia Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning&Development for more information.
151 MAPLE RIDGE RD SM-2013-0062
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
GIS#_ 7338
260 i-t ' 11
Map: 36 `^
Block: SHEETMETAI, PERMIT
Lot: 001 .RM
Permit SHEETMETAL s' rfpa
Category: SHEETMETAL
(Permit# sM-2013-0062 PERMISSION IS HEREBY GRANTED TO:
Project# JS-2013-001820
Contractor: License:
Est. Cost: $65.00 Expires:
1Fee Charged:$25.00 DAVID MICHALOWSKI
Balance Due:$.00 Owner: OSOFSKY JAMES R
I#of Fixtures: Applicant: DAVID MICHALOWSKI
DigSafe# AT: 151 MAPLE RIDGE RD
UseGroup
tass
Cons Cl _ J
ISSUED ON: AMENDED ON: EXPIRES ON: 31-May-2013
TO PERFORM THE FOLLOWING WORK:
BATH FAN
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Sheetmetal REC-2013-006482 30-May-13 4838 $25.00
Inspection Type: Inspector: Date Inspected: Date Signed Off: Status:
FINAL Charles Miller 31-May-13 FULL COMPLY
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov
GeoTMS®2013 Des Lauriers Municipal Solutions,Inc.