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11C-035 City of Northampton Map 11C Lot035 Zone 1B(100)[URA(o)i Massachusetts Date issued 4/11/2016 0:00:00 Inspector of Buildings Permit # BP-2016-1158 Permit Fee$60.00 SIGN PERMIT Business EASTHAMPTON SAVINGS BANK Address 4 HAYDENVILLE RD Applicant InstallerGRAPHIC IMPACT SIGNS INC Applicant Installer Address 575 DALTON AVENUE Work Description REPLACE ILLUM KIOSK SIGNS - EASTHAMPTON SAVINGS BANK Estimated Cost $1872.00 Building Department Approval by: File#BP-2016-1158 APPLICANT/CONTACT PERSON GRAPHIC IMPACT SIGNS INC ADDRESS/PHONE 575 DALTON AVENUE PITTSFIELD01201 (413)443-0034 PROPERTY LOCATION 4 HAYDENVILLE RD MAP I IC PARCEL 035 001 ZONE HB(100)/URA(0)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building,Permit Filled out Fee Paid Tvpeof Construction: REPLACE ILLUM KIOSK SIGNS-EASTHAMPTON SAVINGS BANK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin(Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 L 4----�� -V-f 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. HECEIVED MAR 3 12016 Titlj of Xort4ampton DEPT.C' C7 'TIONS �Ilttl$$Ztl�(lI$Pf�$ NO At 60 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 INSPECTOR Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee (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�. &PLOTv Northampton, Mass. ...............................20..... To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device,or marquee. BUSINESS NAME ... i7>."thc�r,,t;�✓r!►1„Sti i!� ....C��.`?7. ...G` 1./r7.!K t 01.1. .............. 1. Location, Street and No. ...`i... ...................... 2. Owner's name ........................................................................................................... 3. Owner's address ..........I/.............................................................................................. 4. Maker's name ...&t_tYhr.C,.....l!??pa.;.f...14"5- 1,4.4 t I I lb,� .......................................... 5. Maker's address ..5�7.5......44tvX-. 4Tr .........[l.1X1S tm....Ali......c?l.44t./...... 6. Erector's name ...... 5! I.?>C...................................................................................... 7. Erector's address .......... ............................................................................................ SIGN KIND OF SIGN (6-A15 17 NJ (Designate) 1. Sign will be (check one) illuminated .y... Non-illuminated ....... 2. Will sign obstruct a fire escape, window or door? ...N..u, Marquee ............... 3. Lower edge will be ...Y..ft..!?...ins above the public way. Projecting .............. 4. Upper edge will be .!JA...4?..ins above the public way. Roof ..................... 5. Height . —..ft..(,Jns Width ..YA.0...ins Temporary............. 6. Face area .tYS..sq.ft. Wall ..................... 7. Inner edge will be A��from the building-op*ole. Ground ................ 8. Outer edge will be from the building orlele. Other ...AP.12.A.I RSk- 9. Face of building or pole is 39*i;A back from the street line. 10. Sign will project .0...ins beyond the street line. 11. Sign will extend ..U.ft .......ins above the building or pole. . 12. Of what material will sign be constructed? Frame it s........... Face..,K1.9 13. Estimated cost $.....I..y.Y7..A,.0.0 The undersigned certifies that the above statements are true to the best of his knowledge and belief. :.. .....:::,,............. (Signature of Owner o ent 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: 6/Z A P.I'C I MOL-L L- Address: .5-75 &-- (tvN Aa-S' Pi ttrkTk+ ,MA Telephone: 2. Owner of Property: Address: 3C- V 116 y. j kcq-i j2 t—, -. 111A Telephone:L1 1 Z C 7 `f(I I 3. Status of Applicant: v Owner _Contract Purchaser _Lessee ,_/Other(explain): -AAC-Af- 4. Job Location: 4 M/4- Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: i�'-f'L, k,E3 S k- 6. Description of Proposed Use/Work/Project/Occupation:(Use additional sheets if necessary) A T-M �SrN tCzlt.F c' U��� ►���-: ti-t' IsVtC 7 octSdt:�c CCe.ruA� cT0.L�_ (e`f'tLTtV�'/a,- S�drM 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Planse 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW_jZ 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 I/ 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: Are there any proposed changes to,or additions of,signs intended for the property? YES NO IF jYES: Describe the size,type and location: y�—L `� t t 64— cjc t3 1 N O' /](�l W-)ew"t S1f(VAC - c f f kah')t I v 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 Front: Setbacks: Side: L: R: L: R: Rear: Building Height / Bldg Square r 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: �S' �—/ [ APPLICANT'S SIGNATURE J" 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 lk 1 .4 "° C-� tis.0• F-itAl I : graphic o impact dank signs 800.458.2376 fax 413.443.0034 w -[sfMle,ma 01301 107.0" gisigns.com Sales Rep: M.Brazeau " � m Job Name: ESB Bank p�p Job Location:Leeds,MA ATM -- _... Sheet: 1—.fl Date: 3/24/16 Job#: Scale: as noted Drawn by: LH ESB Bank 4 Haydenville Rd. Leeds,MA (2)...faces this size Rev 1 (4)...Replacement Back-Lit ATM Kiosk Sign Faces...NTS cuaowstune 3/16"flat white polycarbonate plastic faces 1st surface applied green and grey translucent film graphics to fit into existing kiosk canopy face retainer system a� „" , (2)...faces this size ^" The Commonwealth of Massachusetts Department of IndustrialAccidents w Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Graphic Impact Signs, Inc. Address: 575 Dalton Avenue City/State/Zip: Pittsfield, MA. 01201 Phone #: 800-458-2376 Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 16 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.E] 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.] fi c. 152, §1(4),and we have no employees. [No workers' 13.M Other Signs 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 information. Insurance Company Name: Granite State Insurance Company Policy#or Self-ins. Lic. #: WC005849357 Expiration Date: 8/19/16 Job Site Address: ano"f( e •���l City/State/Zip: /_etldf, A4- Q jam-, 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. I - SiQnature: Date: 2 Phone#: Z200 `fS Z ,?37(,, 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#: A�RE® 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 CONTACT Lisa Bernard Coakley Pierpan Dolan & Collins Insurance Agency PHONE . (413)664-9366 FAx A/C No:(413)664-4723 26 Union Street ADDRESS:lbernard@epdcinsurance.com INSURERS AFFORDING COVERAGE NAIC# North Adams MA 01247 INSURERAMain Street America Ins. Co. 29939 INSURED INSURER B.NGM Insurance CompanV 14788 GRAPHIC IMPACT SIGNS, INC. INSURERC: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 I A D D L SU_BR LTR TYPE OF INSURANCE WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A CLAIMS-MADE OCCUR DAMAGE T RENTED PREMISES Ea .".n.) currence $ 500,000 BPF9690P 8/19/2015 8/19/2016 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY II JECT 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) $ ALL OWNED SCHEDULED 119F9690P 8/19/2015 8/19/2016 BODILY INJURY Per accident $ AUTOS AUTOS ( ) 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 Y/N X STATUTE I I ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? � N/A 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(2014/01) The ACORD name and logo are registered marks of ACORD INSn25 rgmanii