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23B-046 (230) INSURANCE COVERAGE: � I have a current liar E insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Er Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nnf h:;v the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waive this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner 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 PrnarPCC TncnPrtinnc Date Comments Final Tncnnrfinn Date Cnmm Pntc Type of License: By L7 Master Title ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ Check at www mace gnvlTnl Inspector Signature of Permit Approval Commonwealth of Massachusetts City Of Northampton Date: L/--/ Sheet Metal Permit permit#sal Estimated Job Cost: $ /'`/ 1, ;$-,�3. c � Permit Fee: $ 13 Plans Submitted: YES f/ NO Plans Reviewed: YES NO Business License# Applicant License# Business Information: Property Owner/Job Location Information: Name: 1Qe&6e& S4 eet of e W Vy, Name:coo/fz Street: 46 S- ) -S {overt. Rd Street: 3 D City/Town: 1.ud/, 9!} • City/Town: Telephone: Y1,3 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: HVAC 1- Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: Deln,- �X� Sf:,vr uSUA p% L)N Fi/ZS� i=laUrt Pt,ARn,/�CY 4-/yLSjLA1,1 A,,eL4/ SL Ap& Lei-&4nAJ,, AS Acs DW5 ' F/4ap.,CAle 9- uuii4i S14i',,.less S71eek Dyei-L.,y err FAo," llce,,ts `0 54- ,.✓ /h,r�l,.t.•,,t a/ .,L �CC)uy�� / ,�1•✓ 44/Lejeck &,* Ad,"VP 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-2014-0061 APPLICANT/CONTACT PERSON KLEEBERG SHEET METAL INC ADDRESS/PHONE 65 WESTOVER RD (413)589-1854 PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URBO) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: RENOVATE PHARMACY New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building-Plans Included: Owner/Statement or License 2192 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ATION PRESENTED: pproved 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 Permit from Elm Street Comm' Permit DPW Storm Water Management d���/ Signature oftulldinrofficiSal 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. 30 LOCUST ST SM-2014-0061 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON IGIS#: 9098 Map: -- 23B --- --_� lock: ----- ---04 6 I[ot: - oo l _ .2 SHEETMETAL PERMIT Permit: _ SHEETMETAL — Category: renovation Permit# SN1-2 2014-0061 _ _ _ PERMISSION IS HEREBY GRANTED TO: -- — Project# JS-2014-002072 JI Est_Cost: $,149149,5 523:00 _ 1 Contractor: License: Expires: Fee Chat $ , 1KLEEBERG SHEET METAL INC Sheetmetal-2192 10/28/2015 - - --- - - Balance Due-$.DO �Owner: COOLEY DICKINSON HOSPITAL INC #of Fixtures Applicant: KLEEBERG SHEET METAL INC �DtgSafe# ___ AT. 30 LOCUST ST UseGroup �ConstClass I -- -- - - ---- ----- ISSUED ON. 09-Jun-2014 AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: RENOVATE PHARMACY 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-2014-006985 04-Jun-14 17625 $50.00 212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouck @northamptonma.gov GeoTMSO 2014 Des Lauriers Municipal Solutions,Inc.