32C-013 (14) City of Northampton Map 32C Lot013 Zone CB(100)/
Massachusetts Date issued 5/11/2017 0:00:00
Inspector of Buildings Permit # BP-2017-1282
Permit Fee$60.00
SIGN PERMIT
Business
Address 108 MAIN ST - NORTHAMPTON
Applicant InstallerFERGUSON SIGNS
Applicant Installer Address 3 RAILROAD ST
Work Description NON-ILLUMINATED WALL SIGN - HAVEN BODY
ART
Estimated Cost $850.00
Building Department
Approval by:
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File M BP-2017-1282
APPLICANT/CONTACT PERSON FERGUSON SIGNS
ADDRESS/PHONE 3 RAILROAD ST FIADLEY (413)586-8462
PROPERTY LOCATION 108 MAIN ST-NORTHAMPTON
MAP 32C PARCEL 017 001 ZONE CB(100T
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
LA)
Fee Paid
Tap eofConstructioa NON-ILLUMINATGN-HAVEN BODY ART
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building.Plans Included;
Owner/Statement or License
3 sets of Plans I Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFtJ*MATION PRESENTED:
�1//Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:$
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
-741/7
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.
. i t
C+Tity of Nartliamtrtazz
) rdtassartrusetts LL.
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f r $4 DEPARTMENT OP BUILDING INSPECTIONS
ie .: 212 Main Street • Municipal Building sr a
�`fi '§„ Northampton, MA 01060 °`" moi-
\,hcrroli Application for a Permit to Place or Maintain a Sign
Sidewalk Sign, Marquee or other Advertising Device 9
(Application to be filled out in ink ortypewritten) Numberar.-0.'/Z.....
Plans must be filed with the Build-ng Inppector Erection ( )
before a permit will be granted. Alteration...._......._ ( )
Repair r )
Repainting ( )
Removal ( )
FEE C".'.PAGE°I) PLOT �/
Northampton, Mass. 20..... �y ft 2�7J
To the Building Commissioner: C i(3`41> /�l
Application for a permit to place or maintain a sign or other� advertising device, or marquee. V D
BUSINESS NAME#.T YIW ;8.0.DY Atr$
1. Location, Street and No. 4D^�/....ITL,fl//✓Dp4 2 /j�J/k'7f�1R`M%'T9N..Mk.91060
2. Owner's name`.D,14 -SLILL1Vf1 MV..C7' S!)NISi (NC
3. Owner's address ((62 -54ArJnE.'�7g.. t... ..11007.1. .t..t r...V.../uu!it.-...Oj.Q.La0
4. Maker's name _u.E/?t,V Ctd../+M( �(,r ,aft
5. Makers address .3 t/nuagoa>7 .s7,: D4E)V 41* 0035,.,_„..__
6. Erector's name SCitierele.. GGf72.,(✓ .,L� �(�f /7
7. Erector's address 3 kg/am 1,,,,)' -.JT;..'.IA.�.�i�...lU/i[....01.0` ..0
SIGN KIND OF SIGN
(Designate)
1. Sign will be (check one) illuminated Non-illuminated
2. Will sign obstruct a fire escape, window or door? JVQ... Marquee
3. Lower edge will be .. ...ft..b....ins above the public way. Projecting
4. Upper edge will be 1. ..ft 6 ins above the public way. Roof
5. Height ft..3.4.ins Width ft.4.ins ovary
6. Face area .v2Q.sq. ft. ✓
7. Inner edge will be a...ins from the building or pole. .ewalk
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 D....ins beyond the street line.
11. Sign will extend ft 0. ins above the budding or pole. .
12. Of what material will sjgn be constructed? Frame .f rlai liU 4M. Face-AttM.etlrtGLWNt.
13. Estimated cost $..e o ceposrd'Qi
The undersigned certifies that the above statements are true t. .•• .est of his k •wledge and belief.
(Signature of O er t)
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: /IVE/l/ SOD ) . (Pert c<, fENELopE5fiv/= 7-Er4J)
Address: 108 /'WAIN cJt friffi11NPr0A MA Telephone:¢1 4 6.hS
°lobo
2. Owner of Property:� A J'ULl/i'4N U�t cJOI , //t/(
Address: 6� _�"A'� M'XT#" 3'T 11(B/7NR IVI Prt.N;t'171i'Tetephone:. 4-3 .5-e4,43,10___.
tvn
3. Status of Applicant: Owner Contract Purchaser Lessee
.._Other(explain):
4. Job Location: /08 IL1ii// ,j d(75At ron! 44% 0/060
Parcel ID: Zoning Map# Parcel B_ Distdctfs)
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property'.
6. Description of Proposed Use/Work/Project/Occupation:(Use additional sheets it necessary) � ,
r . . _ • - S— �c . /4Slat ,9tra2 .90"x 9L'' SU
at Ali ? 'L....tt-.au."„vl (omposite. et/Jli.., A �.�_
7. Attached Plans: Sketch Plan Site Plan _Engineered/Surveyed Plans
B. Has a Special PermitNariance/Fi " g ever been issued for/on the site?
NO DON'T KNOW 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:_ 1/Lefil7�f_(in c 1., l"✓/T
/lawnlittur box � (x1vc - 20 ' xSZ7 „
Are there any proposed changes to,or additions of,signs intended for the property? YES ✓ NO
IF YES'. Describe the size,type and location: Ara 4 , .to / " . :� CS fa SLC
�z r,� S'r hliGG �?C.��,*'�t IEt :..F3
6
W.
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 jam¢ jf /��fr
Frontage 22 Ai- A
Front:
Setbacks:
sloe: Lc R: 1: R: _
Rear:
Building Height 3
Z 5 51-ov'eS 47A
Bldg Square � f
Footage 725“5
%Open Space: O l
(Lot area minus bldg and
Paved parking)
# of Parking Spaces 0 474
#of Loading Docks O 117A
Fill: (volume a location) /Vg
13. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE:_ ':• _�. �`� APPLICANT'S SIGNATUR
Applicant's Email ••tress (required)
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.
Page 3 of 3
The Commonwealth of Massachusetts
Department of Industrial Accidents
2 — Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /+ �^ //' PleaseOPrint Legibly
Name (Business/OrganizatioMhtdividual):Ce ODD/R... /Wp , t �f is / t q� 3es/ s o Ji)
Address: ,1,7 Et�Sr P1-($5Ap/T SWET
City/State/Zit: ADV gar" M4- 01002 Phone#: 1/3 3-4-' 221-4-
Areym an employer?Check the appropriate box:
Type of project{tayuired):
L VI ! am a employer with /q 4. 0 I am a general contractor and I
employees (full and/or par[-nese).` have hired the sub-contractors 6. ❑ New construction
[-n
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 9 Remodeling
ship and have no employees These sub-contractors have 8. 9 Demolition
working for me in any capacity. employees and have workers'
p 9. ❑ Building addition
[No workers' comp. insurance comp,insurance
required.] 5. ❑ We are a corporation and its l0.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I19 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.9 Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. [No workers' 13.1XOther 5/r✓s-/,k(
comp, insurance required.]
*Any applicant that checks box 1+1 must also fill nut the section below showing their workers.'compensation policy information.
'Homeowners who submit this affidavit indicating they are doingail work anti Men hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this bon must attached an additional sheet showing the name of the sub-amnactors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurancefin my employees. Below is the policy and fob site
information. qqJarp
Insurance Company Name: fiTil1/V r.9./'/AC j$A4ERtC�}- K QRANC(
Policy#or Self-ins. Lic. #: wcr57 2/C Expiration Date: t A,A 7-
Job Site Address: /01(3 /441N t5i/Si-4 j City`StatetZip:/pX7NAnttfib&v, I1 fk 01060
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 DR for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ...... ........ Date:
Phone#:
sr
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#:
Information and Instructions
•
, Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,art employee is defined as`...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as an individual,parmership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MOL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and.if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self insurance license number on the appropriate line_
City or Town Officials
Please be.sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or pennit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
a
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax # 617-727-7749
www.mass.govidia
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