30A-032 (6) INSURANCE COVERAGE:
I have a current,ttablliIy 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 � Other type of indemnity ❑ Bond ❑
OWNI_R'S INSURANCE WAIVER: I am aware that the licensee slne•se have• the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit appilcationmaiuesthls requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner Or Owner's Agent
By checking this boxL, hereby certify that all of the details and information I have submitted (or entered) regarding this application aro true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit Issued for this a ication will be
In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Lows.
Duct inspection required prior to insulation installation: YES NO I
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Date Comments
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TlstP Conini ents
Type of License:
By ❑ Master
Title ❑ Master - Restricted 1
CityfTown DJourneyperson Signature of Licensee
Permit # ❑Journe Restricted -5 74D
License Number:
Fee$ - ❑
Check at www m11 bnvlrtpl
inspector Signature of Permit Approval
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1 ommonwealth of Massachusetts � r'
City Of Northampton s/ c i
CO 01001) Sheet Metal Permit 0131. OF MILDII'40
� Date: Permit #
Estimated Job Cost: $ d Permit Fee: $
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License # 2 L/ !' Applicant License # 5 a - 7 0
Business Information: Property Owner / Job Location Information:
Narne: Atee ftwStlz e, 1 Name: 4 me,/ 1 <"/
Street: 377 /nrj) /Y 5t Street: $' ? o & t vtSQ5a' E O, .
City /Town: 6 firAf i r m ig ic & ti City/Town: 4L' 0471/.1-11
Telephone: Vi 3 - Sod '? 3 a yd Telephone:
Photo I.D. required / Copy of Photo LD. attached: YS NO
Staff Initial
J -1 / M -1- unrestricted license
J -2 / 1V,I -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 kRetail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: 3
Sheet metal work to be completed: New Work: Renovation:
HVAC V Metal Watershed Roofing Kitchen Exhaust System
• Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done:
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Fees with Building Permit: $25.00 Residential, $50.00 Commercial. Fees for jobs without a Building Permit 56.00 per $1000
Minimum fees for jobs without Building Permit $50.00 Residential, $100.00 Commercial
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