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18D-026 (8) ''� The Commonwealth of Massachusetts Department of Industrial Accidents � ' Office of Investigations - • -=� �') 1 Congress Street, Suite 100 Boston, MA 02114 -2017 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers { 4 Applcarit'Infor`mation . , ` Please Print Legibly Name ( Business /Organization /individual): CALLAHAN SIGN, LLC Address: 117 UNION ST P.O.BOX 744 City/State/Zip: PITTSFIELD, MA 10202 '(413) 443 -5931 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. © 1 am a employer with 5 4.0 1 am a general contractor and 1 6. ❑ New construction " employees (full and /or pact- time).* • have hired the sub - contractors 2. ❑ 1 am a sole proprietor or partnex- listed on the attached 'heet. 4 7. ❑ Remodeling ship and have no employees These sub - contractors have " P 8. El working for me in any capacity. employees and have workers' insurance.: 9. E] Building addition comp. [No workers' comp. insurance P• required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 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 repairs insurance required.) t c. 152, §1(4), and we have no employees. [No workers' 13•® Other sign comp. insurance required.) • *Any applicant that checks box tl1 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. if the sub - contractors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and Job site information. Travelers Indemity CO • Insurance Company Name: — Policy # or Self -ins. Lic. #: 6KUB- 5B74571A Expiration Date: 12/19/2013 Job Site Address: 55 DAMON ROAD City/State /Zip: NORTHAMPTON, MA 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. 1 do hereby certi i unde the pains and penalties of perjury that the information provided above is true and correct. Si :nature: James P. Callahan Date / 19/ 2013 Phone #: (4131 43 -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 #: 32 -60592 I Northampton CDJR I 55 Damon Road I Northampton, MA 01060 CM RYS LfR pOm Jeep SIGN DETAIL 9 SERIES CHRYSLER WALL BADGE 8' -6" 6 1/8" C H R Y S L E r2 21" Cr 9' /z" 8' -10 1/2" 9 SERIES CHRYSLER BADGE 9 SERIES CHRYSLER LETTERS Square Footage Square Footage 7.03 ft 4.43 ft Manufacturing Details Manufacturing Details 5 " deep aluminum cabinets, silver returns 3 "deep aluminum cabinets, black returns Formed .118 White Mustang w/ 1st surface digital print White acrylic faces w/ 1st surface black perforated vinyl leaving 1/8 "white perimeter Illumination LED internal illumination,Ventex VenBrite VL -W100 (1) VLP100 -120 LED Driver - 0.5 Amps TOTAL Colors Colors Black MINI Process Black Black MINI Process Black Blue PMS 287 Silver Silver 12 Page 2 of 3 11. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. 12. SEE ATTACHED SITE PLAN This column to be filled in by the Building Department. ' 4 {' Ekisttr9g f Proposed Requir by' Zoning Lot Size Frontage Front: Setbacks: Side: L: R: L: R: Rear: 1' 4 � Building Height Bldg Square Footage % Open Space: (Lot area minus bldg and Paved parking) # of Parking Spaces # of Loading Docks Fill: (volume & location) 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: 2/19/2013 APPLICANT'S SIGNATURE � 1 41 ES P. CALLAHAN NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning Requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Public Works and other applicable permit granting authorities. FILE # Page3of3 • 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,, +LLC — JAMES P: CALLAHAN + ` Address: 117 !TNT ON ST PITTSFIELD, MA 01201 Telephone: 413- 443 -5931 2. Owner of Property: ROBERT S . THOMAS Address: 55 DAMON ROAD Telephone: FAX 2032880233 3. Status of Applicant: Owner Contract Purchaser Lessee XOther(explain): SIGN CONTRACTOR 4., Job Location: 55 DAMON ROAD NORTHAMPTON, , MA 01000 + + Y 4 + + + Parcel ID: Zoning Map # Parcel # District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure /Property: USED PREVIOUSLY AS FORD DEALERSHIP NOW CHRYSLER DODGE JEEP RAM 6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary) SEE ATTACHED DRAWINGS: INSTALL ONE PYLON (8'X12' )SIGN, TNSTAT,T, 1)F.AT,RR NAME LETTERS, INSTALL (1) DODGE BADGE1', INSTALL (1) JEEP BADGE, INSTALL (1) RAM BADGE, INSTALL (1) MOPAR AND INSTALL (1) CHRYSLER BADGE 7. Attached Plans: X Sketch Plan X 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 IF YES: Describe the size, type and location: REMOVAL OF EXISTING SIGNAGE DEPT "customer parking" Are there any proposed changes to, or additions of, signs intended for the property? YES X NO IF YES: Describe the size, type and location: SEE ABOVE FOR THE ADDITION OF NEW SIGNAGE (Ci ofIIrtklttmpiun 8 / i f i) �UlttssttrljusPtts vL- 0. i DEPARTME OF BUILDING INSPECTIONS J.44.1--.___,..V b gij N ? s 212 M ain dtreet • Municipal Building 'i =� Northampton, MA 01060 CC 6 o INSPECTOR Application for a Permit to Place or Maintain a Sign 4 Z Or other Advertising Device, or Marquee ,c (Application �� (Application to be filled out in ink or typewritten) Number • n (X ) Alteration Plans must be filed with the Building Inspector Erectiorectio ( ) before a permit will be granted. Repair ( ) Repainting ( ) Removal.. ( ) FEE PAGE PLOT Northampton, Mass. FEBRUARY 19, 20 1 To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device, or marquee. BUSINESS NAME NORTHAMPTON CHRYSLER DODGE JEEP RAM 1. Location, Street and No. 55 DAMON ROAD NORTHAMPTON, MA 2. Owner's name ..ROB .T...S.,... 4MAS 3. Owner's address 55 DAMON ROAD 4. Maker's name PRINCIPLE USA INC 5. Maker's address 2035 LAKESIDE CENTRE WAY #250 KNOXVILLE, TN 37922 6. Erector's name CALLAHAN SIGN, LLC 7. Erector's address 117 UNION ST PITTSFIELD, MA 01201 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated X Non - illuminated CHRYSLER 2. Will sign obstruct a fire escape, window or door? N Marquee 3. Lower edge will be ft ins above the public way. Roof Projecting 4. Upper edge will be ft ins above the public way. 5. Height ft 21 ins Width 8 ft Ins total (see drawing)WmpoXry 6. Face area 1L.. . ft. Ground 7. Inner edge will be ins from the building or pole. Gtouou 8. Outer edge will be ins from the building or pole. 9. Face of budding 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 sign be constructed? Frame .AL?IMINVM Face AGRXLI.0 13. Estimated cost $.4.00 The undersigned certifies that the above statements are true to the best of his knowledge and belief. (Signat irb of Owner or Agent) f 'i .1 JAMES P. CALLAHAN File # BP- 2013 -0768 APPLICANT /CONTACT PERSON CALLAHAN SIGN COMPANY ADDRESS /PHONE P 0 Box 526 PITTSFIELD (413) 443 -5931 PROPERTY LOCATION 55 DAMON RD MAP 18D PARCEL 026 001 ZONE GI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 3b Fee Paid Typeof Construction: ERECT ILLUM WALL SIGN - CHRYSLER New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PR SENTED: I Approved dditional 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: § 5S ' ? e Z 4 6 Finding Special Permit v 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 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.