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24D-185 (6) Client#:586280 NATIOSIG ACORDr. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/14/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: USI Ins.Services of CT LLC I21CO3 o,E>t):203 634-5700 FAX 203 634-5701 530 Preston Avenue EMAIL (ac,No): Meriden,CT 06450 ADDRESS: 203 634-5700 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Valley Forge Insurance Company 20508 INSURED INSURER B:St Paul Fire and Marine Insuran 24767 National Sign Corporation INSURER C:Transportation Insurance Compan 20494 780 Four Rod Road INSURER D:Continental Insurance Company 35289 Berlin,CT 06037 INSURER E:Continental Casualty Company 20443 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVp POLICY NUMBER (MM/DDIYYY) (MM/DD/YYYY) LIMITS A GENERAL UABILITY 2087995607 01/19/2013 01/19/2014 EACH OCCURRENCE $1,000,000 Ep X COMMERCIAL GENERAL LIABILITY PAEMISEMEoNTEr encel $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JEo [1 LOC $ D AUTOMOBILE LIABILITY 2087995560 01/19/2013 01/19/2014(5aocidaDtSINGLELIMIT 1,000,000 E zl ANY AUTO 4013763181 MA 01/19/2013 01/19/2014 BODILY INJURY(Per person) $ ALL SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ I-X HIRED AUTOS X AUTOS (Per accident) _ $ B X UMBRELLA LIAB X OCCUR ZUP14P2189513NF 01/19/2013 01/19/2014 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10,000 $ C WORKERS COMPENSATION 2087995560 01/19/2013 01/19/2014 X ToRYTUMITS °RH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N 1 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 D DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) This Evidence of Insurance is issued as a matter of information only and confers no rights upon the holder and does not amend,extend or alter the coverage afforded by policies designated on the Evidence. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. 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I e a �, _ m y. a d mZrC tti n m asp C r?,11 O O 0 7 F o'0 3 co ,g� E "4 oomo2 CD p a2v -;-,3,5z0° .5- . to m o c 23 oo. ma •❑❑ (D s 7 N 137 II o Q'� O _. ,n mm O 0 * It") CD (D 7 D s 0 -w (/) C „CD _ - Z (D 0 t3 — t_ z C1 W - .A o ■❑❑ J 1 +sue' co C) Cl) T Z 1l 0(C 1 Qa O 0 S 1). 0 0 7 (' i u3 n a m e Cl got 0 jc -I 'a ca (...3 Z a CD CD N S, = o cn > —I(l) C j Z -< co S K ° 0 CO D) 0 .4 Q 0 o N m' v (N D IN Everbrite Owner consent for sign Installation and permits 12-D L � ,�� Jt Cl . pl operty owner of the tenant space located at (individual's Name) cay �- 3 7/5-;(1 67 `c`' that is occupied by H&R Block do (street address) hereby certify that I am allowing Everbrite, Inc. (and / or Installer) to obtain permits and install signage at the above mentioned address. Everbrite, LLC further agrees that all work will be done in compliance with all applicable laws, codes and ordinance, and any stipulations or restrictions listed on the permits. Removal and Restoration limited to patching of mounting holes from the removed H&R Block signs with paintable caulk or silicone, painting of the patch to match the existing color as closely as local materials allow. Office address: /-5 A c; ki ig/% .a/N1, / a 6 c Signature Name 4=L R L L"'n i/..(' Date 0 . i 1 Page 2 of 3 11. ALL INFORMATION MUST BE COMPLETED:PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. 12. This column to be filled in by the Building Department. Existing Proposed Required by Zoning Lot Size 1. 3 4-c S Frontage 306 4- a Front: Setbacks: Side: L: R: L: R: Rear: Building Height 2 Bldg Square Footage %Open Space: (Lot area minus bldg and Paved parking) #of Parking Spaces N I!- #of Loading Docks /'V Fill: (volume&location) t/1 -- 13. Certification: I hereby certify that the information containe h rein is true and ccurate to the best of my knowledge.101 z D r3 kv G��l DATE: 3 ' APPLICANT'S SIGNATURE 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 3 of 3 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: ' 'T) . I(o N (V 'P, (10 2 Address: R--/CDePc. ',T' " ^ ` << _ j /"t4 Telephone: (e ) 875G - 7 332- 2. Owner of Property: Li) / dr." �-/a'�=t�T4IS� t Address: Li 2)4 Telephone: WV 3. Status of Applicant: Owner Contract Purchaser N,- Lessee Other(explain): 5/CoN INS At l(a'z �C�Z !L i tJ i f +12 e-D c/C-.) 4. Job Location: 11)41 2L-P, hi& $ -i- (+4238 VI t46) - orFi c v9 A!a'. G:SS) Parcel ID: Zoning Map# Z Parcel# 670 District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: SH UPI (N PL4�4. /(C N 7L-i:' 6. Descriptloy of Proposed Use/Work/Project/Occupation:(Use additional sheets if necessary) �l( P(, ((_. L1rI `')TIN (1,111(2 5((2N 7. Attached Plans: v Sketch Plan Site Plan Engineered/Surveyed Plans 8. Has a Special PermitNariance/Finding ever been issued for/on the site? NO DON'T KNO 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: Lk( TIN(d 14-4E (oc1. SICiaN AT I(- 56214- 74-vii) 1--Lp ( 011402 PAWL, N aC ( — T 40)0 CA ),3CC -71i1-:tS i't 7Z is Are there any proposed changes to,or additions of,signs intended for the property? YES y NO IF YES: Describe the size,type and location: IAA Ct l(L -( I-41.kk -6(06 k / -1711. 1,10Vt.- lXl ; I bl%. Gi j 110-N -Ia r) 'Pc_P LA( _ AT 21 •5 5/ T I I t of ur ttm �an 1 f -A,` itassarllusetts * -. t F �`. _ 4 t DEPARTMENT OF BUILDING INSPECTIONS , " t.4 `' , _,.ti01 212 Main Street • Municipal Building �1 sj' v� Northampton, MA 01060 INSPECTOR Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee 2 ��,`37y (Application to be filled out in ink or typewritten) Number T Plans must be filed with the Building Inspector Erection \ ) before a permit will be granted. Alteration ( ) Repair ( ) Repainting ( ) Removal ( ) FEE PAGE Z1k).PLOT 0-70 Northampton, Mass. O( Ioec-2z_ ( 20 13 To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device,or marquee. BUSINESS NAME ��+ 6 C u L dhct # - t E / s �> 1. Location, Street and No. Z ' I(V 4 1- l 23,3 k(NG, /-Po PtAzA) 2. Owner's name L. n b C 7k Gt 2 C_L 7 IL /� 3. Owner's address A &i2 C:_—A i2 I O(;t-(_, AV L.. . `{v H tTL PO-(N 5 Ny IOU OS 4. Maker's name EV C k' 13 (c, (.T C-_' LA C_ i.� 5. Maker's address L{gLiq - Tutu, 41CU S-►7�'c-z.=i 1�.-,k(7-.NF,ILLi), vvi 3220 6. Erector's name I A- I l D lv4 _)I(,,pi , ( U0,' ___ 7. Erector's address O Tb-t`k vl) p L t i N C CU 0 3 SIGN KIND OF SIGN (Designate) 1. Sign will be(check one) illuminated N... Non-illuminated 2. Will sign obstruct a fire escape,window or door? No 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 ft.Z..ins Width .10 .ft 1'14 ins Temporary 6. Face area a1.5.sq.ft. Wall N 7. Inner edge will be ..0.ins from the building or pole. Ground 8. Outer edge will be .iZ...ins from the building or pole. Other 9. Face of building or pole is ins back from the street line. 10. Sign will project 0 ins beyond the street line. 11. Sign will extend -- ft ins above the building of pole. 12. Of what material will sign be constructed? Frame Hti.A.M. Face:4(k'Vt t C- 13. Estimated cost $.2i.QO.Q The undersigned certifies that the above statements a .rueit the e t of hi knowledge and belief. 9 d (l'li1( *t( 5/0,1 ') /I (Signature of Owner or Agent) (.;iv .c 64,L, lick,c-:OCt l i Q tiC 7 iby, 2 /) oLr4,c_ 1,0,4-y —5 i 0t try 0 l/lfvk C'Lr TCa� ��:l}�- ( D ) 5t�,- 7 3 32- File#BP-2014-0578 APPLICANT/CONTACT PERSON NATIONAL SIGN CORP ADDRESS/PHONE 2 PHOEBE WAY WORCESTER (508)856-7332() PROPERTY LOCATION 243 KING ST-H&R BLOCK MAP 24D PARCEL 185 001 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out '713 3 6- Fee Paid Typeof Construction: REPLACE ILLUM WALL SIGN-H&R BLOCK 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 INFQRMATION 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 /177I 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 24D Lot185 Zone HB Massachusetts Date issued 11/7/2013 0:00:00 Inspector of Buildings Permit # BP-2014-0578 Permit Fee$30.00 SIGN PERMIT Business H & R BLOCK Address 243 KING ST - H & R BLOCK Applicant InstallerNATIONAL SIGN CORP Applicant Installer Address 2 PHOEBE WAY Work Description REPLACE ILLUM WALL SIGN - H & R BLOCK Estimated Cost $2000.00 Building Department Approval by: