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24D-202 (5)
File#BP-2019-0814 APPLICANT/CONTACT PERSON JASON HEILMAN ADDRESS/PHONE 26 SOUTH RD HEATH (413)345-9048 PROPERTY LOCATION 43 FINN ST MAP 24D PARCEL 202 001 ZONE URC(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST E OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: DEMO BUILDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 187368 3 sets of Plans/Plot Plan THE FOLLOWING CTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION SENTED: 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 Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay k41 S7`d R(C' Ca w+Ml&8('0 N 18 t, Signature of Building 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 Office of Planning&Development for more information. Versionl.7 Commercial Building Permit Kay 15,2000 jc p !bnentuse only C' of Northampton JAN 16 2419 Buil ing bepartment crPermlf 2 2 Mein Street AL� Room 100 � { DEPT.OF BUILDING INSPECTIt ptOn, MA 01060 NORTHAMPTON A01060 -1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,REPAIR,4RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR 06MUIP ANY BWI..DING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Addy"% This section to be completed by office U3 �ihrl S map 02�O Lot Unit �i-rte,arnP 1 e , m 0 0 110(G v zone overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 4h A r i + 5 S',n•.a t•Thhn��S r 'q•�a Al.,.1 -'Neaia.w P4 flor_<,Cc Name(Print) Current Ma114 Addmess: Signature Telephone 2.2 Authorized Aaent: �n Oy) y-E\Arnc-In slu1-1prru I;Jki MP Name(Pft) -'' Current Mailing Address Signature Telephone SECTION 3.16MTEO CONMUOSPI MM Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant DOW 1. Building 0� (a)Building Permit Fes 2. Electrical _ (b)Estimated Total Cost of Construction from 6 - 3. Plumbing Building Petmit Fee 4. Mechanical(HVAC) 30 5.Fire Protection _. 6. Total=(1+2+3+4+5) 1 15 800 Check Number This Seddon For Official Use Only Building Permit Number IssuedDate Signature: Building Commissionedinspector of Buildings Data rne i �Q.®J p� bujtri.ti , - CZ)(y\ Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wail Signs P Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing[I Change of Use❑ Other❑ Brief Description Of 1)0-rh c- cj—, '145 Finn Proposed Work: l.�i ,'k-ki �AC�1`1►Jt" SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 0 1A ❑ A-4 ❑ A-5 ❑ 16 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential R-1 ❑ R-2 R-3 ❑ 5A S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility [] Specify: M Mixed Use ❑ Specify.'! S Special Use ❑ Specify: i COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: b? o ? Laxxa _ Proposed Use Group: Existing Hazard Index 780 CMR 34): t Proposed Hazard index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE.USE ONLY Floor Area per Floor(s1 1st 2"d 2� 3rd3rd 4d' _ Total Area(si) t yp I� ^ Total Proposed New Construction(so Total Height(ft) { Total Height It 7.Water§upply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public (3 Private ❑ Zone�-1 Outside Flood Zone❑ Municipal 0 On site disposal system[] Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size __3CYt?� Frontage Setbacks Front t i Side L SQL R-Ad--, Rear Building Height -- - -. -_ - Bldg. Square Footage 42 ? Iq % Open Space Footage % (Lot area minus bldg 8c paved [1:0: c parking) #of Parldng Spaces 1 ------- Fill-. --Fill: volume&Loca tion) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW er YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW (J YES O IF YES: enter Book Pagel and/or Document# B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtainedO Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO ef IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,Ttion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 118 CONTAINING MORE THAN 35,000(;.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Applicable ❑ _ t -SIE6FRlEA PetzT►r t �63y ----- , Name(Registrant): ; �r6 �ctAs, ,gT sr stein 311 cAFY)q,4MP70,4 MA RegistrdtionNumber 'Address o$_31-aotq 1Expiration Data �ag-yy3y_ � Signature v Tekomne 9.2 Registe d Professional Engin s): Name Area of Responsibility Address Registration Number Signature Telephone Evkstionosts. - Name Area of Responsthift — , Address Registration Number Signature Telephone Em*a6on Date s` ! Name Area of Responsibility _ Address Registration Number Signature Teleptione Expkation Date r Name Area of Responsibility L Address t Registration Number Signature Telephone Fmiration Date 9.3 General Contractor ' 1 I C NotAppiicabie❑ Company Name: Responsible in Charge of Construction I -,ALI l of ! s Telephone Address Signature Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION,I1-OWNER•AUTHORMATION-TO-BE:G �E OM, h 1lYHEN. OWNOM AGENT OR CON'tRACT�OR APPUESFd*is)J 6W PERMIT i. ` -Ms .__ ___ r T_ _ .J�r,.� , raw._� __.,.__ .._. _ _ n,as Owner of the subject property OF hereby authorize —,Sun _....__j7e��w1Q 1 �. ..__...___ __....__.��___ ______.___. ._.__.�.____ -. _ _ ---.ito act on my atF,i i era 77tD work au=is building permit application. sign re of owner VDate I, A0.sor)'J(Qt t moire __ as owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge 3 and belief. Signed under the Pains and penaiti�s,of pe_IJuiY. ___.. a .. � Print N J _ { l SiQfletlX'8 Ownert' EfltDaft SE ON 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Suggrvieor. Not Applicable ❑ ' Name of License Holder: _ ig3C Marna Number z -0%311 Address _ _ cn Date -- giQne Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(KML a-152;;J.25C(8)) Workers Compensation Insurance affidavit must be completed and submiibed with this application.Faflure to provide this affidavit will result in the denial of the issuance of the building pwm!L Signed Affidavit Attached Yes No From: U'10 ( I n G� � mon. 6 (e) To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at H?5 Eyi n G\ - Ua)r--I-na.m p io r1 ,(Y1 A O1 O GO because the work is of a minor nature,will not affect structural elements, health,accessibility, life or fire safety,and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, ACC> CERTIFICATE OF LIABILITY INSURANCE DA01115/2019 " ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to tho terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in tieu of such endorsement(s). PRODUCER NAIME BetW Wholey-0seil BLACKMER INSURANCE AGENCY INC PHONE 413 625-6527 me : betsy@bwdmers.com 1147 MOHAWK TRAIL INSURER(S)AFFORDING COVERAGE NAIC/ SHELBURNE MA 01370 INWRERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED NISURER S. HEILMAN JASON P DBA JPH BUILDING INSURER C: INSURER D: 9 WILLIAM ST STUDIO 6 INSURER E: SHELBURNE FALLS MA 01370 INSURER F: COVERAGES CERTIFICATE NUMBER: 356749 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ CLAIMS-MADE D OCCUR PREMISES Meoccurtenoe $ MED EXP one Penson) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIAR APPLIES PER: GENERAL AGGREGATE $ POLICY❑WT El LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY jaP:,1NE=D SINGLE UM $ klerti ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS PROPPIERTY GE $ HIRED AUTOS NON-OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE NIA AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION XSTR OTH AND EMPLOYERS'LIABILITY YIN ATUTE ER A OFA F CRERIMEMBEREXM UDE E�D7ECUTIVE NIA WA MIA 7PJUB7H95921818 03/10/2018 03/10/2019 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 100,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AdtYtland Remarks lldwdrde,may be aWdred If mon space Is nmpdred) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration data on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at WWW.MBW.gOV/hvd/workers-compenwM Mnvestiga*ms/- Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Northampton Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZEDREPRESENTATIVE c Northampton MA 01060 �-'_" C� Daniel M. y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. AN rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Cr Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individuai): i �( )i L �J C"? Address: q W I LU A M v l TE �) City/State/Zip: Q�3WPhone#: q 13-44 5 -3 W 5 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with (o 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. (§Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp.insurance. 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ eP 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152,§1(4),and we have no employees. [No workers' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t Ac Y,MF 1z, �kl',qV cLA NCE Policy#or Self-ins.Lic.#: _Mu VA"9 59 Zl 6 l 8 Expiration Date: S 10 U Q Job Site Address: City/State/Zip: k a,,XM AMPMJ . MA _01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci under a pains tt enalties of perjury that the information provided above is true and correct: Signature: Date: J51 1 Phone#: q q-45 - 7O Ofjtcial use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: