24D-202 (10) o�� 5
File#BP-2019-0814
APPLICANT/CONTACT PERSON JASON HEILMAN
ADDRESS/PHONE 26 SOUTH RD HEATH (413)345-9048 p �-
PROPERTY LOCATION 43 FINN ST
MAP 241)PARCEL 202 001 ZONE URCO 00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ti� USEU'.nREQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TyReof 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:
�AFFroved,_ 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 13T011tC— C11"Y141141&Q to t44,� -O j
l fg If 9
Signature of Bui ding 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.
Ycrsion1.7 Commezcial Building Permit Ma 15,2000
Department use only
City of Northampton stag of P"ft:
JAN 16 2019
Builing Department CUfb.CtltJJlrive "4wfnit—
2 2 Mein Stivet
Room 100 Wa*NVel!Avaltabillty j
DEPT OFOUR-DING rNCPECroWth pton, MA 01460 TWO, ol` r:#PwM*
TJGRTHAA4P?ON t O
- -- - -, -1240 Fax 413.587-1272 plot sifo?lans
O?her -
APPLICATION TO CONSTRUCT,REPA1k aENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR Q&66R79 ANY BItR DING
OTHER THAN A ONE OR TWO FAMILY DWELLING --�
SECTION 1-SITE INFORfAATMU 11
1.1 g am; This i to be compl�e6od by*Moo
149 Mair e2! Co! �r/i+ Un
43 010 W v Zone
Ebn St.Distdat CS Did"
SECTION 2-PROPERTY OWNERSHIPIAUTHORMED AGENT
fal- !A t A r I'd1,5
NWm(Pt"
Si�atrrre L2—e Telephone
7-2 gdmd Acent: _
LZ
4 - xq fir?
s Telephone
SECTION 3- 119ATED
ttam Estimated Cost(Dollars)to be ofllclal Use only
cornotated ern*applicant
1. Building .. _ (a)Bu2dft PwmitFee
00
2. Electrical (b)F.stifna*d Total Caast of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.l=ire Protsc bon
6. Total=(1+2+3+4+5 2 S { Check Number
This Seddon For Ot[ictal Use Only
6adtlinp PermW Number Dade
Issued
BuUd Corn of DOW
rn el Casi2)j PYx bu.t Id . ci rr\
a C3 DLLs�c�l
' SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ® Addition ❑ Replacement Windows Alterations) Roofing
Or Doors 0
77
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other[o]
Brief Description of Proposed
Work: 71F(66ri-2 Q� F. SF.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. 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? v'L>
kQ V
d. Proposed Square footage of new construction. ` S dC>F Dimensions 3g x g 7
e. Number of stories? I�o fQ�acL
f. Method of heating? L tn nce 'tcrrJ ljc� Fireplaces or Woodstoves � '�Number of
each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? �v KERS QtihnS
h. Type of construction
r�
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 7 i
k. Will building conform to the Building and Zoning regulations? , Yes No .
I. Septic Tank City Sewer�_ Private well City water Supply K —
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Owner of the subject
property
hereby authorize ��N �i 1,l��ftc Inc
to act on m>be alf, inall, atter elativeto work authorized by this building permit application.
Signature of Owner Date
- as Owner/Authorized
Agent hereby decta e 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 perj7,"")
/ --
17
Print Namw
Signat4r6 of Owner/Agent Date
.............
VersioE1.7 Commercial ftlding Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE I
Interior Alterations D Existing Wall Signs P Demolition 0 Repairs 0 Additions El Aecaosery Building El
Exterior Alteration 0 Existing Ground Sign 0 Now Signs 0 Roofing 0 Change of Use 0 Other C)
Brief Description Of 445 Finn
Proposed Work:
ACA A-Tr
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 0 A-1 p A-2 C] A-3 0 1A 1:1
A-4 ❑ A-5 ❑ 18 0
8 Business ❑ 2A ❑
E Educational 2S ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C 0
Z
I MsUtutionat 1-2 0 1-3 0 36 0
M Mercantile ❑ 4 0
R Residential fff R-1 El R-2 R-3 0 SA Rr
S Storage 0 8-1 0 S-2 0 58 ❑
U Uunty ❑ Spear.
Al Wired Use 0 Spear
S Special Use ❑ specify.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS.ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Tn hQ-acmu-CL or,%ON - 1p,L Proposed Use Group:
Existing Hazard Index 780 CMR 34):' Proposed Hazard Index 780 CMR 34);
SECTION 6 BUILDING HEIGHT AND AREA T
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
lot mi�
U t. 2Ad
P1 Ii.zq& 3rd
Total Area(sf) q0.it 4 Total Proposed NOWN 920lb-COM(I&---
L
Total Height(ft) ToW Height ft
T.Water§upply(M.G.L r-40,§54) TA Flood Zon*Information: 7.3 Sewage Disposal System:
Public 0 Private [] Zone Outside Flood Zoneo Municipal 0 On site disposal systemE]
Versioul.7 Commercial Building Permit May 15,2000
8 NoRTH&mrwxzmwG
Existing Proposed Required by Zoning
nb columna to be filled in by
Bn�dia8 D+epara�mt
Lot Sizer tV-10l
Setbacks
Sic L RE%21 I=•R,=
'_"OU a
Building Heigbt
Bldg.Square Footage %
Open Space Footage % t { �.
(Lot area minas bldg&paved 10$61 tl CF l
#of Parking Spaces
h j
VOtllli7e IIC I.008ti0Il .....-._..___. ._... _. __._
A. Has a Special Perrnit/Varlanee/Finding+ever been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW a YES 0
IF YES: enter Book _# Page�� and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW a YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained a , Date issued:
C. Do any signs exist on the property? YES 0 NO e(
IF YES, describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO or
IF YES, describe size, type and location:
E. Will the oonsfmction activity disturb(clearing,grading,exg1v81lon,or Ifing)over 1 acre or is it part of a common pian
that will disturb over 1 acre? YES 4 NO
nt
IF YES,then a Northampton Storm Water Management Pemtit from tate DPW is required.
Veruioul.7 CommmvW BnIft Pewit May 15,2000
S S'C�"11�i 4,-'�tJ�c ff!'l f . t Sds i C 1�6u'1'Ht�C1'JCAii '$ 'fit �
NNUMMUCTUM VOISMUM
COMMUCT"CONTROL PUMMW TO 780 CUR 146(CM TA Ii M tIOM THM 35,{#80 C.F.OF S CLO9W SPACE)
9.1 Roostered Architect:
SIEfrFRf�A f'� t+SotAppGcatde 0
Name(>3eg�rant). (3 1
mmbw
ErJwr Diu
9.2 R9qkftr&d Prc&sriona!' s
E ! E
Narm Area of Rosp"mgffily
Adftw
PAO*a*a fJtetlbw
5ignauxe TolWmo EMpitaeon Data
Name _ Ams of ReopmmWfty
Sil Ore 7eMph** >*aha Dole
N1lsl! Arm of ResWWblity -
i
Ad*on Rag3slr2 w Plumber
S nehrre
Temptppm ExpirBlit n Date
"Illmie Agee of RasponsiMW
111AlMMR Roosbuban Nwnber
siwmwm T ExSirartion Date
9_3 General C-*retractor
I I dlNotAppecome 13
Compeny Name: u
Response in Charge at C.anstrualion
Address
f. ..y. -aJ"'�C� 3 a
T
Vaaionl.7 Comnat W Building Pa mk May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW f780 CMR lial1J
Ind ndml Structurai En ine&Mg Bbwtu ai Peer Review Required Yes No 0
$M 11-OWNER AWTHORIZATION-TOMC.OPKETED:WHEN,
OWIMW AGENT'OR COWRd CTOR APPLi�I�?tt!Rlf �,PEwtI
!, _ nc . �_.:_ rse.•_• •_ _. _.... __._. .as Q►ar ofi ftre eubJed PIr
tu�by
M. fir %%VA. W,'oy trtfkft
_�.. `•+ .lr 2.x`1 L`�
77,
as OwnerfAuttnortad
Agent hereby declare that On statements and Inilormation an the foregoing application are tno,and accurate,to the best of my kn Medge
and b h:
PrIM N
9lgeuhne.A0wrwWA0wd Date
TF
ON 12-CONSTRUCTION SERVICES
i
i liLl j,ymmmcl- - Not Applic9bte ❑
MM of Licsoiss Holdw f
Lic", umber
�_. MIR 11 X311 G Ila �
T
SECTION 13-WORKERS'COMPEL+UTION,INSURANCE AMDAYIT(M.G.L.c.1 52,S 25C(6)}
Workers Compensation Insurance MTkievit must be oompieted and submitted with this application-Failure to provide this affidavit wiU result
in the denial of the issuance of tiro baikfing permit
Signed Affidavit Attached Yes N,0
From: ?JJ 6n ra(9--n
tharn . llS
-g,h ,l.i q
To:
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
lNorthamption, 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,i request that you
grant a modification to waive the requirement for construction control of the project at
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,
Cf�.-
DATE pIrMlDarrrYl
CERTIFICATE OF LIABILITY INSURANCE
01/15J2019
THO'CERTIFYCATE 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 13Y 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 certlNCate holder Is an ADDITIONAL INSURED,the ptorcy(les)must be endorsed. N SUBROGATION IS WAIVED,subject to
the tarns;and cot>dtfions of the po icy,ce taln pokles may require an enclorsemertt. A statement on this cerdficate does not Confer rights to the
cerdfkate holder In Neu of such s.
PRODUCER NAME: Bats Wholey-Qsell
BLACKMER INSURANCE AGENCY INC "HONE (413)625-W27
No);
k. hetwyww*MftM-=n-
11
1147MOHAWKTRAIL -- - +>SuR,�fsRnLR6COVERAG,E PICS
EL
SHELBURNE MA 01370 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674
IN __
INSURER 8:
HEILMAN JASON P DBA JPH BUILDING ft"ERC:
INSURER D:
9 WILLIAM ST STUDIO 6 u4suRER E-.
SHELBURNE FALLS MA 01370 1 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 CLAima
S" ADM TYPE,CF INSURANCE POLICY NUMBER EFF POLICY EXP t.IMns
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-AIAUE OCCUR PREMISES Ea_ _
MED EXP one peason S
NIA PERWNAI A ADV IWURY s
GEn AGGREGATE t GAIT APPLES PER: GENERAL AGGREGATE S
POLICY❑JE ❑LOC PRODUCTS-C OMPIOP AGG s
oTrleR: s
AUTOMOBILE LIABILITY (Es accnied)
_ s
ANY AUTO BODILY INAIRY(Per penton) S
ALL O8 AUTOS NIAWNED BODILY UKXJRY(Por soc brit) S �y
PROPERTY DAMAGE s
HIRED AUTOS AUTOS
(Per aackwo)
S
URIBRBAALIAb OCCUR EACH OCCURRENCE I S
EXCESS LAD a AarB{IgpE NIA AGGREGATE I�S _
DED 1 1 RETENTION 5 S
WORKERS COMPENSATION X D
AND EMLOVERV L.0 ML" Y t N
A a T 6414-
ANYPRDPRMSER XCW IRA NSA WA 7PJU87HM21818 0311 W2018 10311012019 ORIPARTNERIEXECUrIWE E�EACH AccIDENT !s 1.U00.000
(Mandatary In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000
Syes under
DESCRIPTION OF OPERATXNI$bebw E.L.DISEASE-POUCY L"T I S 10o0'000
NIA
1
DESCMPTION OF OPOtATNNIS t LOCATIONS t VONCLEB OWWIW IIK AdMw d Rerrhrb beheddr,mer be admiod Noon space to m4uker3
Worksm'C•ampenseiion benefits ws be paid to Messachuseft enoloyteas only.Purmmdlo Endorsement WC 20 0308 B.no authorization is given to Pay dskm for benefits to
empiayses in states other than Messachusetts If the khsunxi hires,or has hired time employees Dutskia of Massachusetts.
This Caardfieate of kwianee shows the policy In force on the Hats that this certificate was Issued(unless the expiration dots on the above policy precedee the ice"date of this
certificate of lnw rsncs. The status of this coverage can be monitored daily try accessing Ute Proof of Coverage-Coverage Verification Search tool at
WWW.fM=
Sole pwpnef r has not elects coverage.
CERTIMATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VM.L BE DELIVERED IN
Town of Northampton Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main St
AUTHORIZED REPRESENTATIVE
Northampton MA 07080 �M.Ca y CPCU,Vice President-Residual Market-WCRIBMA
Q 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD(lame and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Indrrs#rial Accidents
D,Bice of Investigations
690 Washington Street
Boston,MA 42111
www.mass govldia
Workers' Compensation Insurance Affidavit., BuiidersiContractors/Electri+cians/Plumbers
Apnlcant Information Please Print I.,dbly
Name(Businesslthmnization/individual): s�tt"I t 9 i L t1 C2
A
city/state/Zip: -tft&UoE. �-A }R (} WPhone#: �!S-43 5 - � 5
Are you an emp1oye� r Vned*k the appropAstebox: i-
Type of project(required);
1.® I am a employer with (A2 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. 10 Demolition
working for me in any capacity. employees and have workers'
_ 9. E3Building addition
[No workers'comp.insurance 'comp.ice.
required.] 5. ❑ Weare a corporation and its 10.®Electrical repairs or additions
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
insurance required.]t c. 152,§1(4),and we have no ❑ repair
employees. [No workers' 13.❑ Other
comp.insurance required.]
'Any applicant that checks box#1 mit also fill out the section below shriving their wogs'dation policy fi formation.
t Homeowners wbo submit this affidavit indicating they are doing all wwk and then hire outside cannactors must submit a new affidavit indicating such.
hC'mtractors that check this box must attached an additional sheet showing the us=of the sub-contractors and state whether or not those entities have
employees. If the sub-oontract ors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for mp eirydayan Below is the policy and job site
infermation.
Insumce Company Name:
j3i('1s 1 tf C
Policy#or Self-ins.Lic.#: Expiration
Job Site A : 1u City/StaWZip:_ N NIA C5 6 d
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 Clay 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.
5
I do hereby cell nder ,pains nasties ofperjury jury that the Information provided above is true and correct
i tore: Date: 11 i5l kel
E'
Phone#: ., 1-45 - ?205
OjWdd use only. Do not write in this area,to he compked by city or town offwkL
City or Town: PermlMicense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Peraom: Phone M