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18D-026 (11) The Commonwealth of Massachusetts `= == Department of Industrial Accidents i� - 9 -5 : ; y Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02119 -2017 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applican R , 1 Please Print Legibly Name ( Business /Organization /individual): CALLAHAN SIGN, LLC Address: 117 UNION ST P.0 . BOX 744 • City /State /Zip: PITTSFIELD MA 10202 phone #: (413) 443 -5931 Are you an employer? Check the appropriate box: Type of project (required): 1. © 1 am a employer with 5 4. ❑ I am a general contractor and 1 t have hired the sub contractors 6. ❑ New construction employees (full and /or part time). 2. ❑ '1 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' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ 1 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.❑ 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 # 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. if the 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 s information. Travelers Indemity CO • Insurance Company Name: 12/19/2013 Policy # or Self -ins. Lic. #: 6KUB- 5B74571A Expiration Date: 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 1pumber 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 certil unde the pains and penalties of perjury that the information provided above is true and correct. Signature: T James P. Callahan IDate}/19/2013 Phone #: (413) 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 1 Northampton CDJR 1 55 Damon Road 1 Northampton, MA 01060 ,HR�5LET DODGE Jeep i V ELEVATIONS ... .. ` 35 , w ,,. t b G i a fi t; v--- ; "cam"` r � t t r-0 v , - 3 > a , °" .. -: _..� -� .'tea .w�,a,a , _ -.,.w w ' fi� A A Service' Mopar sign to be centered above entry door. Mullions and other wall accents to be painted Pelican Gray. Building to be painted Pelican Gray. Available wall area for Mopar sign to be verified in field prior to installation. 10 32 -60592 1 Northampton CDJR 1 55 Damon Road 1 Northampton, MA 01060 GN RYS.LER � � � 000�E jeep RwMk � SIGN DETAIL 35" MOPAR SQUARE WITH SERVICE PANEL Square Footage • 10.28 ft' Manufacturing Details • Painted aluminum sign cabinet • Halo lighted clear acrylic logos with 1st surface 9 Y 9 vinyl decoration pushed through painted aluminum sign face • "Service" is non - illuminated vinyl Electrical Requirements • Fluorescent internal illumination 35'/4" (3) F30 / T8 / Daylight / Lamps • (1) Lighting component EESB- 424 -13L Electronic Ballast Colors ✓ Black Process Black, Blue PMS 287 • White' • Silver 23 7/8" 35'/4" 42" e 3 1/8" � H " Service 37/8" 17 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. Existing <' Proposed Required by Zoning Lot Size Frontage Front: Setbacks: Side: L: R: L: R: y A Rear: a' , " i ' 6 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 ' ✓f , 14 a 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 # Page 3of3 Page 1 of 3 THIS FORM IS PART OF THE SIGN PERMIT APPLICATION File No. ZONING PERMIT APPLICATION PLEASE TYPE OR PRINT ALL INFORMATION ' I. Name of Applicant: CALLAHAN SiGN,, ,LLG r JAMES' . CALLAHAN 14 Address: 117 TTNTON ST PITTSFIELD, MA 0 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. 4ob Location: 55 DAMON ROAD NORTHAMPTON, MA, 01060 " Parcel ID: Zoning Map # Parcel # ' Districts) " (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'X1 2') SSIGN, TNSTALL DF.AT,RR NAME LETTERS, INSTALL (1) DODGE BADGE I 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 E)EPT "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 4°-%724-'N, (Iil j of Nnr11 imptnn 5. nssttrlfusrits �' * , -'6. 4fi A ``. f I �4 DEPARTMENT OF BUILDING INSPECTIONS y � r,' �� , F — 1 + 212 Main Street • Municipal Building s riy . -��= Northampton, MA 01060 FEB 202013 INSPECTOR Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee DEPT. OF E, 1:), ih:,rECTIONS NORTHAMPTON MA 01060 (Application to be filled out in ink or typewritten) Numb._ / . .:..,� .. , Plans must be filed with the Building Inspector Erection (X ) before a permit will be granted. Alteration ( ) Repair ( ) Repainting ( ) Removal ( ) FEE PAGE PLOT Northampton, Mass. FEBRUARY 19 20.0 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 . 0$RT S , THOMAS 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 2. Will sign obstruct a fire escape, window or door? X Marquee MOPAR 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 ft 42 ins Width ft 32 •iAi Temporary 6. Face area 10 ft. Wall X 7. Inner edge will be 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 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 ppole. 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 tru to the best of his knowledge and belief. (0inature of Owner or Agent) r JAMES' P. CALLAHAN ot‹. File # BP- 2013 -0771 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)1 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 3d Fee Paid Typeof Construction: ERECT ILLUM WALL SIGN - MOPAR 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 INF9AMATION 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 2 1 az I 1_3 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 Lot026 Zone GI(100)/ Massachusetts Date issued 2/26/2013 0:00:00 Inspector of Buildings Permit # BP- 2013 -0771 Permit Fee$30.00 SIGN PERMIT Business MOPAR Address 55 DAMON RD Applicant InstallerCALLAHAN SIGN COMPANY Applicant Installer Address P 0 Box 526 Work Description ERECT ILLUM WALL SIGN - MOPAR Estimated Cost $3000.00 Building Department Approval by: