31A-076 (15) INSURANCE COVERAGE:
1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes"o❑
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 ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this bov�w 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
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By Master
Title ❑ Master-Restricted
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number: 70
Fee$ ❑
Check at www.mass.gov/dpi
Inspector Signature of Permit Approval
Commonwealth of Massachusetts
plumbing&Gas fnspecti°ns Sheet Metal Permit
Electric,
Northamp ton,MA 01060
Date: Permit#-6 —/0--
Estimated Job Cost: $ Permit Fee: S n I
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# .2 Applicant License# 8 Uq
Business Information: Property Owner/Job Location Information:
Name: Q Gl V i� Name: �oy+t``amOun 1 v I�L�i,l_K 1
Street: �� k Ve Street: a J4 £ ne-e+
City/Town: ��� 1 k0g LLB bD( , 01(0�City/Town: r'I'j�iC�mU )r1 M 010A
Telephone: � � ( - j Telephone: 3) -5�(a - 's .2`S 2-
Photo I.D. required/Copy of Photo I.D. attached: YES NO
Staff Initial
J-1 M-1 nrestricted 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 V 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 r/ Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
CSC n�1P�� remove Dind O i n%e o c)ne yo( n�
r i t
Q i 0 U U�g n t 12 praC t fU C)Da MPrO X04 (— t v er M
�P_k�,t(� t S i hL� t�Pl`� • �Yl��(t(�P_ �`_c'�n nCL"'�l�rl� 'fT� Pk i.S"f'1 s�
terns . yD\j iCP co k!'�tt�D r)cPg o Y �v� -Con t-�-v�C
Cd Pr+r kC:
File# SM-2015-0042
APPLICANT/CONTACT PERSON HURLEY&DAVID INC
ADDRESS/PHONE 90 Fisk Ave (413)732-3141
PROPERTY LOCATION 264 ELM ST
MAP 3 1 A PARCEL 076 000 ZONE URB000)
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: DUCTWORK TO REPLACE ROOFTOP UNIT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 804
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQR'1GIATION 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
lm Stre C ssion Permit DPW Storm Water Management
S ture of uilding Official 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.
264 ELM ST SM-2015-0042
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
�GIS#: 11473
fMap: 31A
Bl°°k: -- - °'-- __-1 SHEETMETAL PERMIT
Lot: 000 „..•
Permit: SHEETMETAL
Category: SHEETMETAL__
!Permit# SM 2015-0042 PERMISSION IS HEREBY GRANTED TO:
Project# JS-2_01_5-002134
Est Cost Contractor., License: Expires:
Fee Charged:$100.00 (HURLEY&DAVID INC Sheetmetal-804 06/28/2015
Balance Due:$.00 _Owner: NORTHAMPTON MEDICAL
of Fixtures _ Applicant. HURLEY&DAVID INC
DigSafe# __ AT. 264 ELM ST
jUseGroup
�ConstClass
ISSUED ON: 19-May-2015 AMENDED ON: EXPIRES ON.
TO PERFORM THE FOLLOWING WORK:
DUCTWORK TO REPLACE ROOFTOP UNIT
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-2015-006268 19-May-15 12904 $100.00
212 Main Street,Phone:(413)587-1240,Fax:(413)587-1272,Email:lhasbrouckgnorthamptonma.gov
GeoTMS®2015 Des Lauriers Municipal Solutions,Inc.