24D-202 (9) o�� 5
File#BP-2019-0814
APPLICANT/CONTACT PERSON JASON HEILMAN
ADDRESSIPHONE 26 SOUTH RD HEATH (413)345-9048 p L-
PROPERTY LOCATION 43 FINN ST
MAP 24D PARCEL 202 001 ZONE URC(100�1
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
E 0513ll REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TvReof Construction: DEMO BUILDING
New Construction
Non Structural interior renovAtions
Addition to Existine
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 Perrnit 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 q 15T01'Je.
lb ee be 9 _
Si ature of Buildin Official Date '
� g
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.
Version 1.7 Commercial Building Permit Ma 15,2000
Aepartr»ent use only
City of Northampton Stars of Permit
JAN 1 6 2019 JBg Department Cuda.Gut1PdUv Loy, wn*,- -
Win Street a 3°9pt)I Availab.H?yoom 10t} fVtrsterNtielt Avetiabitity
Dept.aF surtaArao rNSPEcr, ptc�n, W 01080 T 'S OtrS ffIM11 II Plaits
NORTHAMPTON t A01060240 Fax 413-:587-1272 Ptol 806n1,;ns
01her Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANSE THE USE AR OCCUPANCY OF,OR -9A BU ILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION t-So I E INFORMATION
1.1 TW section to be comIxWed by offices
Map 02 Lot L f
Zone owway QtSwt
Ebn SI.t3tsb t C81,01driet
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
Name V'rInQ Cumrnt Addn _ w
)/ r
&W-0ture Telephone
L2 Atsthtarizest-Asse
nt: t _
Name(Point) Curreed Me111a9 Addras8;
s reieptrone
SECTION 3- TED
s Item Estimated Cost(Dalim)to be Offfclal"use Q*
cam lad by Rem*a icant
f. Building � �y ss Btstld Permit Fee
2. Electrical 1.�� (b)Es trtrarsd TOW Gast of
i Construction from 5
3. Plurnbirsg Building Permit Fee ^j
4. Mechanical(HVAC)
5 Fire Proteetion
11. Totai=(1 +2+3+4+S 1 5 ( ( Check Number
This Section For Official Use On
Rufi€9tng Pent Number Date
Issued
Signatufs:
Bukft CmmmiWonerl of Wid' Data
�mei C 1 . C��
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ® Addition ❑ Replacement Windows Alteration(s) ff— Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [pJ Decks [Q Siding[[--3] Other[O]
Brief Description of Proposed ++ !
Work: gni.. ,':"01. .—C C. I-W'0r t -5 CGS hl1 7,`!l L C1-2 41 23 h,i n SF.
T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing complete the following:
a. Use of building . One Family /< Two Family Other
b. Number of rooms in each family unit: 7 Number of Bathrooms
c. Is there a garage attached? `L5 t:
kQ �
d. Proposed Square footage of new construction. 3 3 d G�F Dimensions 3g x g 7 '
e. Number of stories? I�o cc-
f. Method of heating? L} 1�1<n ace'kctcl 40-$,r Fireplaces or Woodstoves •f`t' r Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
�� &�-5 GZtitn
h. Type of constructionyr�
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar Floor below finished grade/, ii
k. Will building conform to the Building and Zoning regulations? "I Yes No .
I. Septic Tank City Sewer _K Private well City water Supply K
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject
property
hereby authorize ��N 1� ttc Inc..
to act on my b If, in alativeto work authorized by this building permit application.
Signature of Owner Date
I, i^I, Ac # , , as Owner/Authorized
Agent hereby decla a that the statements and information on the forego`g application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties POT.
Print Na
Signatyre of Owner/Agent F Date
..........
Versienl.7 Comma -W Building Permit May 15,2000
SECTIQY 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE I
Interior Alterations 0 Existing Wall Signs P Demolition E3 Repairs 0 AddMon3 Ej Ac"vacry Building 0
Exterior Alteration 0 ExIsOpq Ground Sign[I Now Signs[I Roofing 0 Change of Use 0 Other 0
Brief Description Of 11)tmc OF- 112) Fillrl
Proposed Work.,
u.(+ `(�c rpt �2krnA- 4ACAAJr
SECTION 5-USE GROUP AND CONSTRUCTION r(ft
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 El A-2 C] A-3 ja 1A ❑
A-4 ❑ A-5 0 18 ❑
B Business ❑ 2A ❑
E Educational ❑ 28 0
F Factory 0 F-1 0 F-2 0 2C 0
'6'Hign'Hezarb rL-3 It '� I
I t(IsOuknai 0 11-1 Q 1-2 0 1-3 11 38 r0L
M Mercantile 11. 1 4 13
R Residential f-71 1 R-1 El R-2 R-3 0 SA Ga�
S Storage 0 S-1 0 S-2 0 5o 0
...........
U Utility 0 Specify.
Al Mixed Use 0
S Special Use 13 Spew
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
E)dsfing Use Group: a. b c Proposed Use Group* L-1..
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Flo"Area per Floor(sl)
ist
3r"
4'h
Total Area(sf) Total Proposed Now Conshmadwtoff:
Tcftl Height(ft) Total Height ft
T.Water§upply(M.G.L.c.40,g 54) TA Flood Zor a Inforavation: 7.3 Sewage Disposal System.
Public Q Private Ej zcm I Outside Flood Zone[] Municipal 0 On site disposal system[]i
VersionL7 Commercial Building Permit May 15,2000
i3. NoRiu&mrwxz4DrwG
Existing Proposed Required by Zoning
This cohnnn to be fined in by
Nnes�
Got size .. A-C l_,_
Frontage
Setbacks
Side L•R7a3 R:1FEfl I= R:=
Building Height
Bldg.Square Footage WE 9;iil '/o 1 E ]
(oxtaSpace am minus bldg&pavtd 109t•1 yo
#of ParkiAg Spaces
vattunc Bt
A. Has a Special Permlt/Vatianee/Findtrsg ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (y YES 0
IF YES: enter Book _ Pagel and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? VES O NO e
IF YES, describe size,type and location: i.
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: �
I-. Will the construction activity disturb(c kxvhtg,grading,ex or Sling)over 1 acre or is It part of a common plan
that wilt disturb over 1 acre? YES 0 NO ��
x
IF YES,then a Northampton Storm{Nater Management Pwr dt from tate DPW is
required.
Vermont 7 Coal BurlftPerim May, 15,2004
M ft&ftrW ArcWlert
r S Not AppkaMe
JE6 FRIED
PJecne �: 1 3Y
j 116 1'LUS41Vr ST S,,jTB 31 6 j nr Number
Address e$—31-.Reif
�33•?1-9 3 E*m lon Dada :
8i a ToWphorm
sa ProhneionW :
Nwfte Aree of Rwpora dyr
Siure Tem,«,. MohMW DWW -
Nenfe Arae of RnpmsftNy
Adder
soft" To**A" tie
Arae of ResporiaWky -
Adbw
l�MA4 Aria of
Arida n Nudist'
Sigr�ahrra 7 Eamon Da%
9-S Cienerat Corrtractar
i 1 d NotAppicable 13
c4mpeny Name:
Rmpambe In Ctrge or Camas
Ict
t S
Radress
TWsphorw
Xersionl.7 Coat Building Pernnit Mty 13,2040
SEC2M 10-STRUCTURAL PEER REVIEW#TIS COIR?Tail)
Ind dolt Structural EnginmMg EngineeringStructural Poor Rooew Required Yes No 0
SECTION 11- :A1tTKWdZAT[t2N-TO;eE
AQEN'T OR C0MRA!C M APPLIES F31I 1
--
as thrrter of the eubled ice!'
t�araby
tMAI-
oft Date
b as OwnerlAugwrized
Agent hereby dedore that the sb#Amerda and Information on the foregft sppilaatlon are true and accurate,to the best of my knowledge
and belef.
Si9rwd�rder_the petns_ar ffteC9 t F+awry
t'rirli N _
."„ .
S! gent Daft
SE ON 12-CONSTRUCTION SERVICES
fNot Appicabie 0
c $ _
Telephone
SECTION 13-WORKERW CCtYPt"T ION iNSUttlRMEAFFIDAVI (RLM.,c.15.,,i 26C(6))
Workers Compensation Ins+uranoe aUwjt must be completed and submitted wilt this application_Falure to pnnAft Oft Iddevit wN result
in the denial of the issuance or the btAdkrg parrik
Signed Affidavit Attached Yes OF No 0
a.
w fOfiTt:
0"116 n 6n wo-n
I Al tharn e-F-� C%60au fr6]
Ta:
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
�?) y11'1 �' cfvanaO rl , 20GO
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,
DAM(MAYOD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
01/15/2019
THEE CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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: M the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the term and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certiftcab!older in Neu of such endors s.
PRODUCER NAMEACT: Betsy Wholey-0sFeil
BLACKMER INSURANCE AGENCY INC '"i°"e 413)625.6527 , 149k
'�, het.�t>�t IackmErs.cwn.
1147 MOHAWK TRAIL LNSURE3WAFFORrMCOVERAGE #
SHELBURNE MIA 01370 ei8[IREAA: TRAVELERS PROPERTY CAS CO OF AM 25674
Iftsulm aMaatEx B
HEILMAN JASON P DBA JPH BUILDING INSURERC:
INSURER 0:
9 WILLIAM!ST STUDIO 6 NSUPZRE:
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.
e16n ADM Um TVPV OF INSURANCE POLICY NUMBER LIMITS
POLICY exp LIMIS
COMAIERC1ALGENERAL LIABILITY EACH OCCURRENCE 5
CUUMSA%DE I—]OCCUR EMIags !
MED EXP ore person S
NIA PERSONAL d ADV INJURY S
GEI+iL AGGREGATE LMR APPLES PER GENERAL AGGREGATE S
POLICY❑�C F71
LOC PRODUCTS-COMPIOPA G IS
OTHER: s
AUTOMOBILE LAM T Y COMBIlkIED SWJGLE�� S
ANY ALTO BODILY INJURY(Par Prison) $
�
Q�� OCH NIA
NON-OVrBODILY INJURY(Per aw dant) S
HIRED AUTOS AUTOS
NED DAMAGE
E
S
LIUNtEL LA LLAa OCCUR {( EACH OCCURRENCE is
EXCESS LUa CAIMSMADE NIA ) AGGREGATE I S
DED 1 1 RETEN71ON S
WORPUMCOMPENeATION I X O
AND EMPLOYERS'WB1LITY
ANYPROPRI£TORIPARTNER/EXECUTIVE Y/H ' E.L.EACH ACCIDENT 'S 1,000,000
A OFFICCERIMEMSEREXC.UDEDT NIA NIA WA 7PJU87H%921818 03110!201$l 03110!2019
PAMdatwy in NH) E.L.DISEASE-EA EMPLOYEE i 1,000,000
A deap2fa under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 'S 1,ODOU 000
NIA
DES PJRTI MM OF OPCNATKM/LOCATIONS/VEWCM(ACORD tel,AddikaW MarrMa eolndd%a"be adechad Karen spew 4 n pdro*
Workers'Compenss5on benefits wit be paid to MostecluissUa employees only.Pursuant to Endorsement WC 20 03 06 B,no authorizatiDo is gNw tD pay dairns for benefits to
employees in states other than Massachusetts if the insured hires,or has hired time employees outside of Massachusetts.
This cerdficate of Insurance sham Me pailcy in force on the date Teat this Cert)fk*te was issued(urge"the expiration date on the above policy precedes the issue dot®of We
cartitieats of Yrsuraneej. The status of ft Coverage can be monitored deify t►y acoessing the Proof of Coverage-Coverage VartficaWn Search tool at
vuww.mess tlonsJ.
Sale proprietor Ras 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
AUTHORIZED REPRESENTATIVE
Northampton MA 01060 Daniel M,C y,CPCU,Vice President-Residual Market-WCRIBMA
C 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print L&ibly
Name(Business/organization/Individual): _
no)1 L 1 C7
Addreu:
City/State/Zip:_ (ZQ� A a�f� Phone##: --�
Are you an emptoyer'r Uneek Yee appropriate box:
Type. I am a eneral contractor and I e of project(required):1.® I am a employer with 4
g 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
woticing 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 ® eF►
3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
i' myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required]# c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'comtpensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such.
°Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
es.
employeIf the sub-contractors have etupioyees,they mast provide their workers'comp.policy number.
I ane an employer that is providing workers'compensation insurance for my employees Below is the policy and}ab site
information.
Insurance Company Name: 1 J5AAF A V M( -
Policy#or Self-ins.Lic.#:i �, t 3� {�Q`J Z �,(� Expiration Date:
Job Site AddressA U u SM City/SWXIZip:_ jgH WPMN r4 A 01410 d
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited 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 bisurance coverage verification.
I do herzky certi nder;ke pains,an nalties of perjury that the information,prvvided above is true and correct.
Signa // - Date: Ji i ( _
a B
Official use only. Do not waste in this area,to he completed by city or town official
City or Town: PermitlLicense#
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#: