18D-001 (10) The Commonwealth of Massachusetts
Department of Industrial Accidents
-'' Office of Investigations
i,_ -_.-: 1 �w 1 Congress Street, Suite 100
t . • * . _ , 1 Boston, MA 02114 -2017
= t www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): Callahan Sign Company, LLC _
Address: 117 Union Street
City /State /Zip: Pi ttsfi el c1,MA 01201 Phone #: (413) 443 -5931
- Are you an employer? Check the appropriate box: Type of project (required):
1. ® I am a employer with 7 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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance.:
9. ❑ Building addition
[No workers' comp. insurance p
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.2 Other Signs
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.
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
employees. lfthe sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name: The Travelers
Policy # or Self -ins. Lic. #: 6KUB- 4915P17 -0 -12 Expiration Date: 01 -04 -13
Job Site Address: Verizon, 162 North King Street City/State /Zip: Northampton, NA 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 hereb / ce�ii under the ' ains and ' enalties o • er'u that the in ormation provided above is true and correct.
Signature: ® .�Al. ! I _ � � / �� Date . a
Phone #: (413) 443 -5931
Official 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 #:
F „
Wireless Zone: North Hampton, MA 2012
Survey Photos & Specs:
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This drawing s the property of Pop-Graphics Inc. and all rights to its use for reproduction are strict) reserved by Po Graphics Inc.
9 P 9 P Y Y P
38 Elm Street l
[--------1 LandiordApprov:1 Landlord Approval Signature &Date:
Meriden, CT 06450 Approved — —
._ Fax: 203- 630 -2780
Phone: 203- 639 -1441 R 0 Appro ed As Noted
Web: pop-graphics.com S
, 00, , s ,„ ., , ,
L w Approved
Not -reuse As Noted
Wireless Zone: North Hampton, MA 2012
25 SQ FT 132" - - --
-
I 11
27 "l _ _
I iI,t of J j &wire ess
wireless Z Nt I
Premium Retailer
Newly Proposed Sign
- ` LED ILLUMINATED CHANNEL LETTERS a CLOUD SIGN ® ,0
± 1 Rot xn Material .040 Alumawm BLACK
2 face Material 3/16' Aay1ite Acrylic sheet with matte Mack HP vinyl on lower cabinet 1
', n on 3 Letter Backs yr Alrninum -
sis
4 Face Deis s4 Check & Z Aaylite red 211 -1 all others Aayl to white 015 -2 1 - ,
S Face Retainer i' Troup Mack and Red for the check and Z 1
..
•
6 7 Remote Power Su L1GHTI US LED white/Red te(Red LED 1 �■
nply Sloan 12 Volt power snooty mounted m raceway. disconnect t switch on raceway •
8 R eeway/Mounti g 118' did, 8` x 8" extruded aluminum Raceway with fasteners through wali 1 i 9 Exrsdrg facade Brick or block 1
10 Electrical Source / Voltage Behind facade 120 volts
11 Channel Clad Sign Same specs as letters
12 Mounting Bar 2`x 2' x 1/4` &m um Angle- tropainted to match raceway
UL Listed sign with UL label on end of raceway
i
This &awing is the property of Pop - Graphics Inc. and ail sights to its use for reproduction are strictly reserved by Pop - Graphics Inc.
- - Mien Street C i Landlord 8 Date:
Meriden, CT 116459 0 I
Far 293- 639 -2799 i d I ■ ❑ APProved
_ Mom: 293- 639 -1441 R ❑ Approved a
Wen: pep- graphlcs_com nave : :r f v c x; w r> l J Not Approved
-revise As Noeea
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
Department
EXISTING PROPOSED REQUIRED BY
ZONING
Lot Size
Frontage
Setbacks Front
Side L: R: L: R: L: R:
Rear
Building Height
Building Square Footage
Open Space: (lot area
•
minus building £t paved
parking
# of Parking Spaces
# of Loading Docks
Fill:
(volume £t location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: 7 ` i 112_' -- Applicant's Signature 64, vts2� -P - C'
NOTE: Issuance of a zoning permit does not relie applicant's burden to comply with all zoning
requirements and obtain all required perm s from the Board of Health, Conservation Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
W: \Documents\ FORMS \original\ Building - Inspector\Zoning - Permit- Application- passive.doc 8/4/2004
k
Page 1 of 3
THIS FORM IS PART OF THE SIGN PERMIT APPLICATION
File No.
ZONING PERMIT APPLICATION
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:Callahan Sign Company, LLC
Address:117 Union Street Pittsfield, MA 01201 Telephone: (413) 443 -5931
2. Owner of Property: Big Y Foods, Inc. RE Manager— Pamela McCarthy
Address: Roosevelt Ave. Springfield, MA 0110Ef"elephone: (413) 504 - 4101
3. Status of Applicant: Owner Contract Purchaser Lessee
X Other(explain): S ign Contrac tor
4. Job Location: Northam. ton MA 01060
Parcel ID: Zoning Map # Parcel # District(s)
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure /Property: Verizon
6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary)
-. -- .
A 27" X i32" aluminum LED illuminated channel letters and cloud sign. Face
material is red, black and white acrylic.
7. Attached Plans: x Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special PermitNariance /Finding ever been issued for /on the site?
NO DON'T KNOW X 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 x 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 X _ NO
A similar sign is on the storefront.
IF YES: Describe the size, type and location:
Are there any proposed changes to, or additions of, signs intended for the property? YES NO X
IF YES: Describe the size, type and location:
Marti famptrat
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«!. DEPT. OF BUILDING I as, �.� Ma T OF BUILDING INSPECTIONS mod *
NORTFIgMpTOp� Moot V 1) al Street • Municipal Building " , `�o
Northampton, MA 01060
INSPECTOR Application for a Permit to Place or Maintain a Sign
Or other Advertising Device, or Marquee
(Application to be filled out in ink or typewritten) Number
Plans must be filed with the Building Inspector Erection ( X )
before a permit will be granted. Alteration ( )
Repair ( )
Repainting ( )
Removal ( )
FEE$30 PAGE PLOT
Northampton, Mass. 10./31 201.2
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
BUSINESS NAME Verizon
1. Location, Street and No. ...162..Noxth..Ki rag.. St; r. eet ..... .N.oxthamp.tQn,..NA..QJ.0.60
2. Owner's name ..B tg..Y..k'QQds...Lao RJ a.. Mazlagcr- 1?a1n4eia
3. Owner's address 2145..Roo sevelt..Ave PQ.13.ox..7.8.40 S.p.ringf.ield,.JY'IA. 01104 -7840
4. Maker's name POP Graphics
5. Maker's address 38 Elm Street Meriden, CT 06450
6. Erector's name Callahan ..S.ign..Camapny,...
7. Erector's address .41.7...ilnion.s.Me Pittsfie.ld.,..MA.0120.1
SIGN KIND OF SIGN
(Designate)
1. Sign will be (check one) illuminated X Non - illuminated
2. Will sign obstruct a fire escape, window or door? ...N4... Marquee
3. Lower edge will be 12 ft ins above the public way. Projecting
4. Upper edge will be 16 ft ins above the public way. Roof
5. Height ft.. 27..ins Width ft.132.ins Temporary
6. Face area . 25.. sq. ft. Wall X
7. Inner edge will be ..2,. ,ins from the building or pole. Ground
8. Outer edge will be .. ..ins from the building or pole. Other
9. Face of building or pole is 96 ins back from the street line.
10. Sign will project NA ins beyond the street line.
11. Sign will extend NA ft ins above the building or pole.
12. Of what material will sign be constructed? Frame Aluminum Face Acrylic
13. Estimated cost $ 3,000
The undersigned certifies that the above statements are true to the best of his knowledge and belief.
, ,.
(Signature of Owner or Agent)
RECEIVED
CALLAHAN -
2012
; OF BUILDING INSPECTIONS
N
S G CO M P A N Y, LLC THAMPTON MA 07060
October 31, 2012
Mr. Louis Hasbrouck
City of Northampton
Dept. of Building Inspections
212 Main Street
Northampton, MA 01060
RE: Verizon Wireless, 162 North King Street, Northampton, MA 01060
Enclosed is our sign permit application for the above location. There was an existing building
adjacent to our location that has now been razed. We are proposing to install one new 25 square
foot sign containing channel letters on the side elevation as outlined on the attached drawing.
We previously submitted our check in the amount of $30 to cover the sign permit fee with the
original application that was denied. It is my understanding we do not have to issue another
check. Please contact me once the permit has been approved so we may proceed.
Should you need additional information or have any questions, please don't hesitate to contact
me at (413) 443 -5931, Ext. 105 or Cathy McCarron at Ext. 104. Thank you!
Sincerely yours,
CALLAHAN SIGN COMPANY, LLC
p 6t6,kiti„,
James P. Callahan
Sales Manager
Enclosure
JPC:cmm
117 Union Street
P.O. Box 526 Pittsfield, MA 01202
Phone (413) 443 -5931 Fax (413) 448 -2251
www.callahansign.com
File # BP- 2013 -0491
APPLICANT /CONTACT PERSON CALLAHAN SIGN COMPANY
ADDRESS/PHONE P 0 Box 526 PITTSFIELD (413) 443 -5931
PROPERTY LOCATION 162 NORTH KING ST
MAP 18D PARCEL 001 001 ZONE HB(100)/WP(16)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out L g 7 O
Fee Paid
Tvpeof Construction: ERECT ILLUM WALL SIGN - VERIZON
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 87859
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOAVIATION PRESENTED:
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
dor /
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.
City of Northampton Map 18D Lot001 Zone
HB(100) /WP(16)/
Massachusetts Date issued 11/2/2012 0:00:00
Inspector of Buildings Permit # BP- 2013 -0491
Permit Fee$30.00
SIGN PERMIT
Business VERIZON
Address 162 NORTH KING ST
Applicant InstallerCALLAHAN SIGN COMPANY
Applicant Installer Address P 0 Box 526
Work Description ERECT ILLUM WALL SIGN - VERIZON
Estimated Cost $3000.00
Building Department
Approval by: