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/
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�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.