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RALPH,S BLACKSMITH SHOP
36 SMITH STAEr NONE'4191 786-5595
NORTMANIPTON,MA 01060 FAX (413)585 C234
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CONTRACTOR -
DATE •••/-:._-.!::. DRAWN BY z-.4"-k _
CONTRACT 1,,,_, DRAWING
NUMBER 1,-/-4- NUMBER ---' .-
• .
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DEPARTMENT OF BUILDING INSPECTIONS
• ' 212 Main Street • Municipal Building '
Northampton, Mass. 01060 y 11011'
WORKER'S COMPENSATION INSURA.NCk, AFFIDAVIT
I, 11It\1 P S 1 tiCSb t('TI+ She)P Su C.-_
(licensee/permittee)
with a principal place of business/residence at:
•
3 ( SMITH-- ST- (phoney#) 5 eG--35 Ss
(stmt/ci ty/st ateM p)
do hereby certify, under the pains and penalties of perjury, that:
Y ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
1
Co mmE.r ( vws y oOLI by 0393 _ 12- 3l-0?.-i
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,r
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
-
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additionl abed if ncoex.sry to include information p,erta∎eing to all cornradors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware:that while homeowners who employ persons to do nzniatcnancc wastru cion or repair work on a dwelling of
not more than throe units in which the homeowner resides or oa the grounds appurtenant thereto are not generally considered to be
employers under the worker's comp=saiion Act(GL152,ss 1(5)),applination by a homeowner for a license or permit may evidence the
legal stet.;of an employer under the Workers Compensation Act
I understand that a Dopy of this ctalcmcat may be forwarded to the Department of Industrial Aazdent?Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties . .
consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine 0[3100.00 a day against mc..
For dcpsrtmerenl use only
I Permit Number
- `1 (z.1 4Z-- Mao_ Lot#
Signature of Liccnsce/Petmittee to
3 a�ci it•1 rte' --
,
s
Versionl.7 Commercial Building Permit May 15,2000
ECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
dependent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
ECTION 11 -OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNER3S'AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT',
, as Owner of the subject property
ereby authorize to act on
iy behalf, in all matters relative to work authorized by this building permit application.
gnature of Owner Date
, as Owner/Authorized Agent
ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
lowledge and belief.
,gned under the pains and penalties of perjury.
int Name
gnature of Owner/Agent Date
,ECTION 12 -CONSTRUCTION SERVICES
0.1 Licensed Construction Supervisor: A Not Applicable ❑ p
ame of License Holder : JTp�lft'1' K 10011 C s 00041 1
License Number
1 3 fZuss CAA.VIU;E Ro. Coll-fl ( z062..,
,idress SOVTli+PtvAProA.) MA. 0107% Expiration Date
s12.— 1%00
gnature
/
;ECTION 13 -WORKERS' COM•ENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(6))
•
Yorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
Jill result in the denial of the issuance of the building permit.
signed Affidavit Attached Yes ❑ No ❑
, i
Versionl.7 Commercial Building Permit May 15,2000
ECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
:ONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
.1 Registered Architect:
Not Applicable ❑
ame(Registrant):
Registration Number
ddress
Expiration Date
ignature Telephone
■2 Registered Professional Engineer(s):
ame Area of Responsibility
ddress Registration Number
ignature Telephone Expiration Date •
ame Area of Responsibility
ldress Registration Number
gnature Telephone Expiration Date
ame Area of Responsibility
ddress Registration Number
•gnature Telephone Expiration Date
ame Area of Responsibility
ddress Registration Numt:::r
ignature Telephone I Expiration Date
1.3 General Contractor
TWCOP GOMPA1J`C Not Applicable ❑
;ompany Name:
ST-PcIU -AcTwOn9
esponsible In Charge of Construction
1
'4% LV( Rom
ddress 'SO 'retPOM.P1"6►J r Mc;• t� t3 •
■40 _ s- l— 1 trod
gnature � I Telephone
Versionl.7 Commercial Building Permit May 15,2000
Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
iblic ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size /2 ACRE
Frontage 3 o' '10
Setbacks Front �6
Side L: 4 R: LC.A. R: I Z—�
Rear
Building Height
2..(7. , 1 21 V°
Bldg. Square Footage Z.o,00a 7.2 % i poo
Open Space Footage %
(Lot area minus bldg&paved 1 235 00 q Q A�v
parking) 1Z.,.8 .-2`
#of Parking Spaces ZOO
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES ✓
IF YES, date issued: 1 'A E C0
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW ✓ YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES ■
IF YES, has a permit been or ne to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
/
IF YES, describe size, type and location: 1'5 1.6 Z X-1
D. Are ere any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
• •
'1
■
Versionl.7 Commercial Building Permit May 15,2000
ECTION SERVICES FOR PROJECTS LESS THAN 35,000
UBIC FEET OF ENCLOSED SPACE
terior Alterations Existing Wall Signs Existing Ground Signs Additions fg Roofing ❑
❑ ❑
xterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ S-rc,It.PsC,V-- Accessory Building[ ] Repairs [ ]
ECTION 5- USE GROUP AND CONSTRUCTION',TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
Assembly I❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
Business ❑ 2A ❑
Educational ❑ 2B I ❑
Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
High Hazard ❑ 3A ❑
Institutional ❑ 1.1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑
Mercantile ❑ 4 ❑
Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
Storage I27 S-1 ❑ S-2 ❑ 5B I ❑
Utility ❑ Specify:
Mixed Use ❑ Specify:
Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
fisting Use Group: Proposed Use Group:
[sting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
ECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
OFFICE'USE ONLY
or Area per Floor(sf) lst 'd:7) X --(,O'= (000 5.'F r h
I BJ000 2nd "
Id 2..0 C30 3rd
4th
d
"h 5W :',,V",',,,''',!:::' _ i,
D t a I Area (sf) 20000 Total Proposed New Construction (sf)
I OOO
2.. -r� €
�tal Height(ft) �
Total Height ft ' i`l �� £ 3 N - '''',4t'
;; a
Versionl.7 Commercial Building Permit May 15,2000
. .. orthampton �.- t ..- .-4,..... � 3 w.
�} L u I►. ii.l Department ', �,� � -
V 2� 2 ° ain Street mss
'' m 100 � RS �
° APR ;j . „
1 7 2wgrth: • on, MA 01060 �� � �
3
—phone 413-5:7-1240 Fax 413-587.1272 i ,i ,, � � -: ,�
APP RUCT, RE'AIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to cor le te= b 'offl c
,'
1.1 Property Address: R ;k
:fit% , 61 :� ,
N 02TltM�ro� Zone Overlay Dtstrtct ( & R
EIm'St.District KGB Dis[ct �y .
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
?.1 Owner of Record:
R k 1
�LPt-% . T40MPSol,3 TC, SMIT'1-E ST
Jame(Print) Current Mailing Address:
z _ S 8C,-3535
Signature v Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
[tem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
_. (a) Building Permit Fee
1. Building 8800
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
f/ /
4. Mechanical (HVAC) j ii
5. Fire Protection / / .,.,/r
6. Total =(1 + 2 + 3 + 4 + 5) $$00— Check Number G 49
TrThis Section For Official Use Only
Building Permit Number: Q� '-- , Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File 1;13P-2002-0885
APPLICANT/CONTACT PERSON ATWOOD COMPANY
ADDRESS/PHONE 143 RUSSELLVILLE ROAD (413)532-1100
PROPERTY LO ee 020A ; , t' ' ST
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ■ i
Fee Paid / ' l'A op - "YI_ /
Or
Typeof Construction: CONSTRUCT 40 X 25 STORAGE SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 000479
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION NTED:
Approved /" d 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 Co 'ssion
-4-it6/,_e_ 6 Loa 2_____
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.