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32A-123 (8) �- � i � 4 � x r I graphic • impact AL 51_15 800.458.2376 fax 413.443.0034 FIN Ica •i` a a gisigns.com a;a> pure Barre* � © pure barre Sales ReO: J.Renzi Job Name: pure Barre Job Location:Northampton,MA ,io�: :,_ .. a Sheet: 1 of i Date: 9/30175 Job#: Scale: as noted Drawn by: LH Pure Barre 63 King Street Northampton,MA APPROI£D MAtO.ED-.OT® • QIENT.ON nn dnE iu ACCOR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 9/10/2015 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 rCONTACT Lisa Bernard Coakley Pierpan Dolan & Collins Insurance Agency PHONE (413)664-9366 FAX (413)664-4723 A/C No: _ 26 Union Street ADRIESS:lhernard0cpdcinsurance.com INSURERS AFFORDING COVERAGE NAIC# North Adams MA 01247 INSURERAMain Street America Ins. Co. 29939 INSURED INSURERBNGM Insurance Company 14788 GRAPHIC IMPACT SIGNS, INC. INSURER C.Granite State Ins Co 575 DALTON AVE INSURER D: INSURER E: PITTSFIELD MA 01201-2908 1 INSURER F: COVERAGES CERTIFICATE NUMBER:2015-2016 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. INSR ADD UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER M D IYYYY) (MWDDIYYYYI I LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A CLAIMS-MADE �OCCUR DAMAGET RENTED 500,000 PREMISES Ea occurrence $ BPF9690P 8/19/2015 8/19/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 O POLICY JE LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: EPLI $ 10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ AUTOS OWNED AUTOSULED M9F9690P 8/19/2015 8/19/2016 BODILYINJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ ELITE $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION CUF9690P 8/19/2015 8/19/2016 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X I STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? FN] NIA C (Mandatory In NH) WC005849357 8/19/2015 8/19/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Office of Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. Municipal Building 212 Main Street AUTHORIZED REPRESENTATIVE Northampton, MA 01060 Lisa Bernard/LIBBER ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 onl4m 1 The Commonwealth of Massachusetts Department of IndustfialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 WWW mass govl&a 1i'orkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Graphic Impact Signs, Inc. Address: 575 Dalton Aveenue City/State/Zip: Pittsfield, MA. 01201 Phone#: 800-458-2376 Are you an employer?Check the appropriate box: Type of project(required): I ✓]I am a employer with 1 6 employees(full and/or part-time).' 7. [:]New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] I I I 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.E]Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0✓ Other Signs 152,§1(4),and we have no employees.[No workers'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 informmtion. Insurance Company Name: Granite State Insurance Company Policy#or Self-ins. Lic.#: WC 005849357 Expiration Date: 08/19/2016 Job Site Address: City/State/Zip:)faha *n1; AA 0/c 6C) Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerdfy under the pains and penalties of perjury that the information provided above is tote and correct Signature: O ZfL " C Z2 1-2 Date: /0z7z S "- Phone#: 800-458-2376 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#• The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Graphic Impact Signs, Inc. I 1LW_ _9_ Address: 575 Dalton Aveenue City/State/Zip: Pittsfield, MA. 01201 Phone#: 800-458-2376 Are you an employer?Check the appropriate box: Type of project(required): 1.D I am a employer with 16 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.[]l am a homeowner doing ll work myself r 9. ❑Demolition g y [No workers'comp.insurance required.] 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I L E]Electrical repairs or additions proprietors with no employees. 11❑Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other Signs 152,§1(4),and we have no employees.[No workers'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. tContractors 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Granite State Insurance Company Policy#or Self-ins. Lic.#: WC 005849357 Expiration Date: 08/19/2016 Job Site Address: �?k_(r4 , =(-- City/State/Zip:_)J0tJAdr,.l,-{aN; �(� o!c6C) Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eerdfy under the pairs and penalties of perjury that the information provided above is true and correct Signature: � L " CJ_A1jt_ ZD �--2 �' Date: /fOZ?z Phone#: 800-458-2376 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#• 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 Frontage N Front: Setbacks: Side: L: R: L: R: Rear: Building Height Bldg Square Footage %Open Space: (Lot area minus bldg and Paved parking) r #of Parking Spaces #of Loading Docks /U Fill: (volume&location) r/ . 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: /D--7—/S' APPLICANT'S SIGNATURE NOTE: Issuance of a zoning permit does not relieve an appli { burd n 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 ' "7 �-- File No. ZONING PERMIT APPLICATION -. PLEASE TYPE OR PRINT ALL INFORMATION tl' I. Name of Applicant: Address: elephone: '7&c% t1U 2. Owner of Property: 6t^eer%G-eCJ Coo",ta nvs- i?c+jk�- Address: 7 k a� S•� ='r '�"t�.ri ftn., �1/� Telephone: X 3. Status of Applicant:_Owner _Contract Purchaser _Lessee _ZOther(explain): St err, e-" l� etcI/cc 4. Job Location: Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: f- 6. Description of Proposed Use/Work/Project/Occupation:(Use additional sheets if necessary) 7. Attached Plans: ✓ Sketch Plan Site Plan Engineered/Surveyed Plans 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW V/ YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW v 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 ✓ /fad IF YES: Describe the size,type and location: Are there any proposed changes to,or additions of,signs intended for the property? YES �.� NO IF YES: Describe the size,type and location: 001"-) Clkc-rw z( 1`r' U." �'1, "- � s cl.. S i L A- i I c 1 ­-12 �"CCiS b'1'h 'I-ew,w..-} All w V24, ti t:-.: c'IN fJ r '�hFtit/ly-" JI G t✓� o+ C� TRIJ of xort4amptjan - f �vK ,�IF188Elth1l8Ptt8 ,� tG i...� t t ' DEPARTMENT OF BUILDING INSPECTIONS Jr: 212 Main Street • Municipal Building Northampton, MA 01060 r= _ INSPECTOR Application for a Permit to Place or Maintain a Sign 1 Or other Advertising Device, or Marquee (Application to be filled out in ink or typewritten) Number ..................... O Plans must be filed with the Building Inspector Erection..................( ) -6. before a permit will be granted. Alteration.................( Repair.....................( ) Repainting...............( ) Removal..................( ) FEE........PAGE........PLOT....... Northampton, Mass. ...............................20..... To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device,or marquee. BUSINESSNAME .......:C..� . .l:...... .......................................................... 1. Location, Street and No. .....lu.. ...... .!!•5 .....51' .�.... ,fL c ,;r2�C ?�r:f??!"j....✓(!l.' .... 2. Owner's name .. ... l.....Ceep....c;1.. S.'f................... n.�$ `vtv fcr. 3. Owner's address .....(a..7......(.... /..........�.............. ........�........�...................................... 4. Maker's name G....... 1.!�?�J(�4I ...��...5 h) .......................................... 5. Maker's address ..S'7. :...... �.�. .!`'.. -.......si..t m.f .�ld......!.k.L'`:�...�h3a 1 6. Erector's name ... -.... .hype,. . f... ...................................... 7. Erector's address S . a ................... � ......, AA.A.....4 ........? .. SIGN KIND OF SIGN (Designate) 1. Sign will be(check one) illuminated ....... Non-illuminated .. 2. Wiil sign obstruct a fire escape,window or door? ...N.0 Marquee ............... 3. Lower edge will be ..`-j.ft..�A...ins above the public way. Projecting .............. 4. Upper edge will be ...ins above the public way. Roof ..................... 5. Height ..i...ft./b..ins Width .j. ftJ..ins Temporary............. 6. Face area/.Yi,0si q. ft. 7. Inner edge will be ......ins from the building or pole. / Ground ......... ...... 8. Outer edge will be .......ins from the building or pole. N//Y .•.•...••.• 9. Face of building or pole is 1.0... back from the street line. 10. Sign will project V...ins beyond the street line. 11. Sign will extend .©...ft .......ins above the building or pole. 12. Of what material will si n be constructed? Frame .....p1�? r �.... Face..Ig!v`?` ""�... 13. Estimated cost $...&._G.,9..tPo. The undersigned certifies that the above statements are true to the best of his knowledge and belief. ......... �:q? ; if - .......... ( natdre ner r Agent) ��.,.L.1 ^f-c'��c=-r.�'t -J C S:�.. .'llv1� //��.i•sh.'.✓<� _J. File#BP-2016-0480 APPLICANT/CONTACT PERSON GRAPHIC IMPACT SIGNS INC ADDRESS/PHONE 575 DALTON AVENUE PITTSFIELD01201 (413)443-0034 PROPERTY LOCATION 63 KING ST MAP 32A PARCEL 123 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT 44 pb Fee Paid T 90 Building Permit Filled out Fee Paid Tvneof Construction:_ERECT NON-ILLUM GROUND SIGN-PURE BARRE 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 PRESENTED: proved 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 10 eS Signature o uilding 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 32A Lot123 Zone CB(100)/ Massachusetts Date issued 10/15/2015 0:00:00 Inspector of Buildings Permit # BP-2016-0480 Permit Fee$100.00 SIGN PERMIT Business PURE BARRE Address 63 KING ST Applicant InstallerGRAPHIC IMPACT SIGNS INC Applicant Installer Address 575 DALTON AVENUE Work Description ERECT NON-ILLUM GROUND SIGN - PURE BARRE Estimated Cost $650.00 Building Department Approval by: Y • - signs T fax 413.443.0034 NORTHAMPTON cooperative Bank A C*A%io►of G940nf W C000P(~8W* Sales Rep: J.Re-i A- Job Name: Pure Barre If Date: 9130/15 Job kale: as noted Pure Barre 63 King Street Northa NWV 0 v a r - . _. 'k K • - AW _ M. 1' (1)...Double Sided Non-Illuminated Tenant Sign Panel....NTS 18"x 117"x 7 deep aluminum fabricated pane(...white background with 1st surface applied opaque red vinyl film graphics designed to mount/install between existing brick columns