24D-161 (4) The Commonwealth of Massachtesetts
��—
Department ofIndustrial Accidents
— _" )+1-_ ,_ Office ofInvestigations
600 Washington Street
= Boston, MA 02111
4' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information `` 6 Please Print Legibly
Name ( Business /Organization/Individual): �i D , 6 fro. ? r G i ou ! { _i k < •
Address: q & r.5 1-o I n v ti
City /State /Zip: 5 - L- as4-u r°o A4 i Phone #: SO 1 236 8 C
Are you an employer? Check the appropriate hox: Type of project (required): Ir
1. I am a employer with a 0 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. t 7 ❑ Remodeling
ship and have no employees These sub- contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building.addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.BOther S rah = ^-r' i'
comp. insurance required.]
*Any applicant that checks box #1 must also Ell out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name albs sub•contractms and their wotimts' comp polity intimation.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. /14
Insurance Company Name: /1
06 CIA. ' " LI + .--i—vt L
Policy # or Self-ins. Lic. #: 1 9 S 5 S Q Expiration Date: - /'
Job Site Address: - - - • - - _ City/State/Zip: �
Attach a copy of the workers' compensanun 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.
1 do hereby or* under the pains and penalties of perjury that the information provided above is true and correct
Signature- )/ f )�L — Date:
Phone #: SD 8 .a38 ` &3 c- )
•
Official use only. Do not write in this area, to be completed by city or town Weird
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 #:
AWNING 1
I 1
i'-6" 1 1 20' I id sign
GROUP INC.
JN Phillips Auto Glass ...1
WorkOnletri:
1 -877 -AUTOG LASS
J 64-10317
1----
Giant
1 TN PHIW PS AUTO GLASS
NEED TO APPLY NEW TRANSLUCENT RED VINYL r-
I Date: 4-27-12
SIDE VIEW
L ltevIsion: 1
Matedals:
l NTERNALLY ILLUMINATED AWNING
, Quantity: 1
., 1 r/Poshrlo:
; 144.46.4444414414.4.;.4 1 ',7 ' 71. 4 4 1 . titrit '7 4:4 0 1 , coNore " frioe; WotIoNt;ttrofigirif;;;;IO;14.;$4.1::414464:4 ,
1 LOGO
,
(4:1:11f$ I Sleets):
$fat:P;fffeecteoter:Preeol:44$$$$$$$$$$$$$P.44:44$4.44:(4:44:44$$$$$$$$$$gettortre.440:40.fen$ 1 SIDED
1
i Graphics:
N/A
4
Graphia Color:
N/A
. 1
-0
4 Dadtground:
N/A
1
•
JN Phillips Auto Glass i
- - - -- -, -- #7 1 T.' -, - ,,, ' - '-•v - , ;-, -:"..;., 1 Dadrgreund Cater:
W"';' ' ``' 1
N/A
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Mountin
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I MOUNTS 10 1-111 PLYWOOD WALL
A * ' (NORTHAMPTON LOCATION)
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FADE/U(710N WILL NOT BEGIN Mit
ID SIGN GROUP HAS RECEIVED 1NE
A0410410 AND 9GNED PROOF BACK
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CONCEPTIJAUPROPOSED (NOT TO SCALE)
SIGNATURE 0 Appimyto
DATE 0 RIVISEANDRESUBMIT
Page 1 of 3
THIS FORM IS PART OF THE SIGN PERMIT APPLICATION
File No.
ZONING PERMIT APPLICATION
PLEASE TYPE OR PRINT ALL INFORMATION , � �--
4
1. Name of Applicant: ey4 <S 64 -b-L� ci 4i ✓ ' 2 = I G�'/1 f l't-tto
Address: 713/k /s)ZV) )II / So, c Cs)0h Telephone: 5-e` o_ 3 e '-6 c
2. Owner of Property: A// C K v- 3 & i) /� / A (�L,O, y /
Address: (f( / VL /)1 /Jh /1 / / / / Tellephone' � / �3 '3 Iti 3 c 5 c
3. Statuspf Applicant: Owner Contract Purchaser Lessee
(/Other(explain):L (9n ��,rni J CA_(_i
4. Job Location: ! 1 . a I S ' ''
Parcel ID: Zoning Map # Parcel # District(s)
(TO BE FILLED THE BUILDING DEEPARTMENT) i Q.A.
5. Existing Use of Structure /Property: .ic y/ QS S' ,rte l ./n.
6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary)
■
L ro
/ / !' 1 t I (5 ' . :I 4' .,t, ' / t n.1h / L J
7lc —e, &C - C�-- a.i Gt. / )` TL A c cA
7. Attached Plans: • Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Spe ' I PermitNariance /Finding ever been issued for /on the site?
NO ✓ DON'T KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: Enter: Book Page and /or Document #
9. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES
IF YES: Has a permit been, or need to be, obtained from the Conservation Commission?
Needs to be obtained Obtained , Date issued
10. Do any signs exist on the property? YES ✓ NO
IF YES: Describe the size, type and location: Cl / c./ j 7f).S v v )14
GSA /tS
Are there any proposed changes to, or additions of, signs intended for the property? YES NO
IF YES: Describe the size, type and location:
. ...__.___.
. RED. _... .
Mg 102012
ar . .
t j of Norp- am}><ton
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PL OF BUILDING INSPECTIONS
NORTHAMPTON MA01060 tassnrtiusrtts *
, DEPARTMENT OF BUILDING INSPECTIONS s- ti,$
' w till Main Street • Municipal Building � 'fry ? `
Northampton, MA 01060
JN�l'T( TOR Application for a Permit to Place or Maintain a Sign
Or other Advertising Device, or Marquee p) Acil9
(Application to be filled out in ink or typewritten) Number I f l
Plans must be filed with the Building Inspector Erection ( )
before a permit will be granted. Alteration ( )
Repair ( )
Repainting ( )
Removal ( )
FEE PAGE PLOT
Northampton, Mass. 20
To the Building Commissioner:
Application for a permit to place or maintain a sign or other adv� device, or marquee.
i BUSINESS NAME . 4 P/ ai i , 1 /I /% 4I 6- et S.s (-1)
1. Location, Street and No 7 . ....1 / SY/ ---C
2. Owner's name g/Af / / Al 1 // Ps & k o tl . c7,
3. Owner's address .L 1 CIV/' .- 4.h9 04(1 Lk '(J'% 12 rd.-) n / 472j''
4. Maker's name .. 11 /il £ "i /1 (1:4-s t =C1 (-f- 4..- ") /k5)
5. Maker's address // \ f
6. Erector's name .f h • 6C(O/4 S C 7 4 4.... ,„a r . . S / . . i . . 1 60
7. Erector's address?. 31E'./ S A I Ri e.. 4Jl , ! ° t `fl 4Jv / ` a '76
SIGN KIND OF SIGN
(Designate)
1. Sign will be (check one) illuminated Non- illuminated
2. Will sign obstruct a fire escape, window or door? ..A(0. Marquee
3. Lower edge will be ft ins above the public way. Projecting
4. Upper edge will be ft ins above the public way. Roof
5. Height .. - ins Width cO.ft ° ins Temporary
6. Face area . sq. ft. Wall
7. Inner edge will be ins from the building or pole. Ground
8. Outer edge will be ` ins from the building or pole. Other . A..vrt it-‘9
9. Face of building or pole is ins back from the street line.
10. Sign will project ins beyond the street line.
11. Sign will extend — ft "-- ins above the building or pole. /
12. Of what material will ign be constructed? Frame /!• "' 0144-1." if
/
13. Estimated cost $ / 9n.- .N//9 J di kt // 071 - 1 y, ,
The undersigned certifies that the above statements are true to the best of his knowledge and belief.
(Si nature of Owner or Agent)