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17C-214 (6) .4'.. \ . - .):,- ,. ''',1\,,,t 1 tfi ' a S. .,"�'`K;°r,+si.:x {, . x�"�4')M ;<ix;'.:Y:;. `+ r';fix ? ap around aeon • AAA"�� ilk+c.e _ •a•'. :axx: TAP OM / i :r; u` is , //,,, ...../........... � °`� .. . r...x«„f::-.i .... 'YS:Yom'+.*:^E:.. .:'.. ... ..°.=•.G iK:3."xrKr.6k..w...na,.¢.n 4 / C E, a fx ::' E. :t e.1 r s S ) vk �•yA �` it: "''"",a•; • • l'i. r110. 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Gi' ....\ = t.r .. ...,.,..,:.• ,....„.„..,....,:..,,,,.:.:.:„......::.„.......,,.....,..„...;:....., . . : ,... .1=■ --.1 _%. 1 li I 1 • - 0,7 o ',-:-.17'.. 6% 0•■'‘) ' 1;)+ co 3 co --,- >< —#-. = .....-.-% ......, The Commonwealth of Massachusetts Department of Industrial Accidents l.i Office of Investigations 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Anelicant Information Please Print Legibly Name(Business/Organization/Individual): c,,c \C e \� y` . J V Address: City/State/Zip: • - - ► a Phone#: 55.q-9 5S Are you an employer?Check the appropriate box: Type of project(required): 1.u 1 am a employer with �,-. 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. Ei Demolition working for me in any capacity. employees and have workers' g Y P tY t 9. 0 Building addition [No workers' comp.insurance comp.insurance. required.] 5. 0 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.[ Cher comp.insurance required.] Any applicant that checks box CI 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 information. Insurance Company Name: \\7 eft J. V t Policy#or Self-ins.Lic.#: [,Ti C° - - rapok (- C Expiration Date: \\ Job Site Address: k, {L-ec a-1'1)J c ( va ) City/State/Zip: 0 101v O 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct S Date: 'S( Signature: ��J, , Phone#: ''l - S`‘. <— 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#: ' t. 1------ , 50 .,........... . . . .. ., .„ . .:.,.. . ...-..-.,... H , . ... ., . . ... . .. ..---.,,.....,:.... ... _. . ..... .. ,. „. ..,, . ,.,.... P...v. D L ci! ,,„ -••••• ,,,..: ..,... '''::::-.;;;..,,,,,,.,i7:,';':,.,:'? " 8 .... ......,........... ..... g 0, ,-, ........ ., .. ., ..... .. .. ...,. . i-' o ^ 1' v rion5 L.)_ ... t z 0 .4 cci : 0 3 a a 3 -,.:il.f;.f,4=Xt.,::: '''.''''' i--,.':.• .........„,. ,,,,„ ..,.....,....,.,... ....s.:.„„, ....v .-- .i:.ii'.,ii.;5';..3rtil':.:.i•i's?..ic'erif.3g.?,; a) 2"(g-,c,113 :,-r Go, ,-.,,,,,,,,,:,,,,..--, i', .,,,.z i-,. .-11::::.:.-!---.,„ ....,,,,, O_) ''''"g'ZI .... .,,.... .5 i g 3 ,......,...„.,.... . . .... ,. . . ... . ...... . .... . . ........ .. . . :‘.e, g . . .. ... . .. ,,,5.-. 0 .. = w IN . ,..,. ...... . . ....„..........,....... ...„...... ...., ... . . .... . ,. ....... ... . . . . . ,.. . . ... . . . ., .., . . . .. . . . ..... - . . .. ..- . . ,. F '..'1,1, :;' .'.. ' -...,,,:...-•-.! 'TCJ 0 0 .t—.1 ... ............: i..::.-.,.,.:.'.;•.:..''-..,:.:..... :rf; x ..... -..-. .,........:, CSi' p--I ,.......,.......„,...:,,,..,.; (-) ...„„„..„.,..,..... .: .... .,. -4. —.1 _.. A --.. r...) . k,... , .P.*:...., .. ....... . . .., .. . .. . — .....,. _., ...... ,. ..... ._, ..., . .• . r.... , ..,‘.. [ '..:-.... ''-'' -0 07 - B. -..-:, ,,.,-,', ..,.,• . i 0 cp . , ,.., .,,.., 3 . _ cp = ,,,.....„,. CD >< cn -.-. = 10. Do any signs exist on the property? YES NO IF YES, describe size, type and location: r e ti vr, l�5- 41 %kat vAr_ Are there any proposed changes to or additions of signs intended for the property? YES 1 NO IF YES, describe size, type and location: a5 i c o \ c e SI \Y\- C� \\■ c c4 ,r r" 11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common s.,......r.4,.....1,,........t 44...4..Al 1 AL-440.4. , .-1 ...........7 vice yin tip° 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 veserued Jar use ay the nutiatng Department FYTQTTATil I TMefil IQFT! II AVM TTAVII PV I - - - ZONING I Lot Size Front a ! I N I I Vaathaarke Frnnt I I I I { Side L: R: L: R: IL: R: IRear N I I I I I Building Height { Building Square Footage 1%Open Space: (lot area I I 4 mini te hintrlin<t Cl- navaA i I ii I Iparking : I I aii I aau n111$5 44+eaa.es I I#of Loading Docks I I T 4 I,-.0 1 I fT1il. I i(volume Et location) { 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. c- vain. I Y I C ✓ Apv;ken si a 3isl IOW'er NA. '\cv NOTE:Issuance of a zoning permit does not relieve appli 's bur•en to comply with all zoning requirements and obtain all required permits •m the Bo • of Health,Conservation Commission, Historic and Architectural Boards,Department o '. , • orks and other applicable permit granting authorities. W A Documents\F ORMSi originallBnilding-InspeetorlZoning-Permit-Application-passive.doc 8/4/2004 Fi10 Nn_ ZONING PERMIT APPLICATION(§i0.2) Please type or print all information and return this form to the Building Inspector's Office with the $15 filing fee (check or money order)payable to the City of Northampton 1. Name of Applicant:__ \5n, Address:_ "3 t e l �1 �c i\ Telephone: '4( - 2. Owner of Property: v.e ..Q c∎ -,c Address: e\°I 1Ce �v� It �.4-• o r� Telephone: 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain) o l � Parcel Id: Zoning Map# Parcel# District(s): In Elm Street District In Central Business District (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: o. PIupt eu Ube/vvoi K/PI Viet-V v A.UNdUU1I: (Use dUUIUUUIdt sheers 11 IIeLeSSdi y j: ,�5 -��'\ 4' x k 5 e_\e�� 1. Attached Pians: Sketch Plan ✓ Site Tian Engineered/Surveyed Pians 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW ✓ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# 9.Does the site contain a brook, body of water or wetlands? NO /f 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: (Form Continues On Other Side) W A Documents\FOKMSl onginaltBuilding-lnspectorlbmung-Yemut-Application-passive.doc 8/4/2004 . _ RECEIVED C ' ' y of Northampton d ' " Massachusetts CD._ INI 13 2013 y 1 ,1 TNIENT OF BUILDING INSPECTIONS_ 21• Main Street • Municipal Building}� PT.OF BUILDING INSPECTIONS NOrt2laIDpton, MA 01060 y.W. NORTHAMPTON,MA 01060 INSPECTOR Application or a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee n�I J�B� (Application to be filled out in ink or typewritten) Number Plans must be filed with the Building Inspector Erection ( before a permit will be granted. Alteration...... ( ) Repair.. ( ) Repainting ( ) Removal ( ) FEE........PAGE........PLOT....... Northampton, Mass. ....:-5./.'7...... ....2O.1 To the Building Commissioner: Application for a permit to place or maintain a trgri or other advertising device, or marquee. BUSINESSNAME ...... .-.-,Y..'5......A c v . :.yl........................................................ 1. Location, Street and No. ... .t....1Xi •r4..... 2. Owner's name ..c.\.C.c vN.c.-e_.. .o.3,4..�1 .?..m. .I-Q t-\.sg- ..1,..1..C.r 3. Owner's address ...` .q... . o... .... -......k_. ...tl.4 ce. .,.... .-k.....©\S.leb 4. Maker's name ... k.0.. ....\.>~.cNu m.. ., ................................. 5. Maker's address ._. .lo.1.......0 .r..s�.e: .. :.... � i ... .- ....0 .Ic .V3 .t.4 n..... e-7-0U•�rxVs-A•C u� .I..° 1i ........... 6. Erector's name ...� • 0.„y�� ,.....C,�.l .l3. 7. Erector's address .. . Ka.l..avvs.co.it e e:... .::..,.... .'Q e•r•••■••• SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated " Non-illuminated ....... 2. Will sign obstruct a fire escape,window or door? ...&o... Marquee ...... 3. Lower edge will be ..li,..ft..:s-..ins above the public way. Projecting 4. Upper edge will be ..1 .ft °&..ins above the public way. Roof ............ 5. Height ..`t..ft ins Width ..Lp.ft..1...ins Temporary 6. Face area ... sq ft. a4-•3a 9. •-r- 3` — Wall 7. Inner edge will be ..::'.ins from the building or pole. Ground ...Q.o\.e.. 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 ..Q-..ins above the building or pole. 12. Of what material will sign be constructed? Frame ...c>A. t-m. -i4. . Face..e t■l c.OL00 _- 13. Estimated cost $... 'O..sa.D The undersigned certifies that the above statements are true to the st of his knowledge and belief. '::-.-.... Ai'. ..'''' ,.. . ... Y. Cmxt,Z .,........... n ur of Owner or Agent) Page 1 of 3 File#BP-2013-1086 AO t..0 "'' (i)(i 5111jQ Alit,APPLICANT/CONTACT PERSON SIGN TECHNIQUES INC W,. 0 CAS Q(,i f.1 A.ADDRESS/PHONE 361 CHICOPEE ST CHICOPEE (413)594-8886 /v` ELK P�p�,;F D u'-o �� s P P6(1- PROPERTY LOCATION 99 MAIN ST r •L1 Li 11SO • ' MAP 17C PARCEL 214 001 ZONE GB(100)/ V.3 THIS SECTION FOR OFFICIAL USE ONLY: �' ��, i p Iv - PERMIT APPLICATION CHECKLIST CA , „-�JI IS ENCLOSED REQUIRED DATE l� ` ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid t>27V07 s 430 Typeof Construction: INSTALL ILLUM SIGN CABINET ON CLOCK POLE 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F ATION 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 Si!_ ol .nD; :O ficial Date - /-1(5 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 17C Lot214 Zone GB(100)/ Massachusetts Date issued 6/7/2013 0:00:00 Inspector of Buildings Permit # BP-2013-1086 Permit Fee$30.00 SIGN PERMIT Business JJ'S TAVERN Address 99 MAIN ST Applicant InstallerSIGN TECHNIQUES INC Applicant Installer Address 361 CHICOPEE ST Work Description INSTALL ILLUM SIGN CABINET ON CLOCK POLE - JJ'S TAVERN Estimated Cost $3560.00 Building Department Approval by: