18D-026 (7)Are you an employer? Check the appropriate boa:
The Commonwealth of Massachusetts
❑X 1 am a employer with 5
Department of Industrial Accidents
6. ❑ New cogstruction
Office of Investigations
-
1 Congress Street, Suite 100
ship and have no employees
Boston, MA 02114-2017
r—
www.mass.gov1dta
Workers' Compensatiop
Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
, §.1 .1 + Please Print Legibly
CALLAHAN SIGN, LLC
Name (Business/Organization/Individual):
Address: 117 UNION ST
P.O.BOX 744
City/State/Zip:PITTSFIELD,
MA 10202 (41'3) 443-5931
Phone 4:
Are you an employer? Check the appropriate boa:
Type of project (required):
❑X 1 am a employer with 5
4. ❑ 1 am a general contractor and 1
6. ❑ New cogstruction
employees (full and/or part-time).*
:. ❑ I aln a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
#
7 ,, E] Remodeling
ship and have no employees
' These sub -contractors have
g. ❑ Demolition
working for me in any capacity.
employees and have workers'
9. ❑Building addition
[No workers' comp. insurance
comp. insurance.
required.]
5• ❑ We are a corporation and its
10.0 Electrical repairs or additions
. El 1 am a homeowner doing all work
officers have exercised their
1 l .❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.] t
c. 152, §1(4), and we have no
13.91 Other sign
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.
I 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.
Travelers Indemity CO
Insurance Company Name:__
Policy # or Self -ins. Lic. #: 6KUB-5B74571A Expiration Date:
12/19/2013
Job Site Address: 55 DAMON ROAD City/State/Zip: NORTHAMPTON, MA 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 DIA for insurance coverage verification.
I do hereby cern undthe pains and penalties of perjury that thein ormation provided above is true and correct
James P. Callahan IDate4/19/2013
4
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 #:
32-60592 1 Northampton CDJR 1 55 Damon Road I Northampton, MA 01060
Jeep
8'-10 1/2"
11 1/8'
9 SERIES DODGE
Square Footage
;, 8.31 ft2
Manufacturing Details
5"deep aluminum cabinets, silver returns
White acrylic faces w/ 1st surface red vinyl leaving 1/8"
white perimeter
LED internal illumination, AgilightTuffRayz LEDs
1-60 W - 0.63 amps Advance Ballast
Colors
Red PMS 485
White
Silver
13
t, , .
E
Page 2 of 3
11. ALL INFORMATION MUST BE COMPLETED: PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
12. SEE ATTACHED SITE PLAN This column to be filled in by
the 6uildinn nanartment
M
13. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
i�
DATE: 2/19/2013 APPLICANT'S SIGNATURE
j ES P. CALLAHAN
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
FILE #.
n
Exisfing '^'
Proposed
Required by
Zoning
Lot Size
Frontage
Front:
Setbacks:
Side:
L: R:
L: R:
r'
d A
,d
' d { Rear:
Building Height
Bldg Square
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.
i�
DATE: 2/19/2013 APPLICANT'S SIGNATURE
j ES P. CALLAHAN
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
FILE #.
n
Page 1 of 3
THIS FORM IS PART OF THE SIGN PERMIT APPLICATION
File No.
ZONING PERMIT APPLICATION
PLEASE TYPE OR PRINT ALL INFORMATION
CALLAHAN SIGN, 'ILO, - J HIES P. CALLAIIAN "
1. Name of Applicant: `
Address: 117 UNION ST PITTSFIELD, MA 01201 Telephone: 413-443-5931
2. Owner of Property: ROBERT S. THOMAS
Address: 55 DAMON ROAD Telephone: FAX 2032880233
3. Status of Applicant: _Owner _Contract Purchaser _Lessee
XOther(explain): SIGN CONTRACTOR
4.ti Job Location: 55 DAMON ROAD NORTHAMPTON, MA 01060
y �
Rarcel ID: Zoning Map # Parcel # ` District(s) "
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property:
USED PREVIOUSLY AS FORD DEALERSHIP NOW CHRYSLER DODGE JEEP RAM
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary)
SEE ATTACHED DRAWINGS:INSTALL ONE PYLON (8'X1_2`)SIGN, INSTALL DRAT,FR NAME
LETTERS, INSTALL (1) DODGE BADGEi-, INSTALL (1) JEEP BADGE, INSTALL (1)
RAM BADGE, INSTALL (1) MOPAR AND INSTALL (I) CHRYSLER BADGE
7. Attached Plans: X Sketch Plan X Site Plan Engineered/Surveyed Plans
8. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW X 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 X 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: REMOVAL OF EXISTING SIGNAGE EXEPT "customer
parking"
Are there any proposed changes to, or additions of, signs intended for the property? YES X NO
IF YES: Describe the size, type and location: SEE ABOVE FOR THE ADDITION OF NEW SIGNAGE
INgPECTOR
Titg of Xort4ampton
ussar4usptts
_1
I
PT. OF B��LDikG INSPECTIONS
NORTHAMPTON MA 01060
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street . Municipal Building
Northampton, MA 01060
Application for a Permit to Place or Maintain a Sign
Or other Advertising Device, or Marquee 76,7
(Application to be filled out in ink or typewritten) Number .....................
Plans must be filed with the Building Inspector
before a permit will be granted.
Erection..................(X )
Alteration .................( )
Repair .....................( )
Repainting ...............( )
Removal ..................( )
FEE........ PAGE........ PLOT.......
FEBRUARY 19,
Northampton, Mass . ...............................20.1.3
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
NORTHAMPTON CHRYSLER DODGE JEEP RAM
BUSINESS NAME......................................................................................................
1. Location, Street and No. 55 DAMON ......
ROAD NORTHAMPTON..,...MA................................
.............................
2. Owner's name ....ROBERT. 5..., THOMAS
.............................................................................
3. Owner's address...55 DAMON ROAD
.....................................................................................................
4. Maker's name......................PRINCIPLE.....USA ......INC............................................................................
5. Maker's address .2.935...LAKESIDE..CENTRE.......
WAY #.2.5.0.250.....KNOXVILLE..., ......
TN 3.7.9.2.2.....
.........................................................
LS
6. Erector's name ... CAL................AHAN..........IGN., .........LLC ...................................................................
7. Erector's address ... 117 UNION ST PITTSFIELD, MA 01201
..................................................................................
SIGN
KIND OF SIGN DODGE
(Designate)
1.
Sign will be (check one) illuminated X..... Non -illuminated .......
2.
Will sign obstruct a fire escape, window or door? .X......
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 ...... Width A..ft1Q..Jns
Temporary .............
6.
Face area 8.t 3 sq. ft.
Wall .X ..................
7.
Inner edge will be ......ins from the building or pole.
Ground ................
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 .......ins above the building or ppole.
12.
Of what material will sign be constructed? FrameAL...I...INUM..........
FaceACRYLIC
13.
Estimated cost $ 3,,.0(TO
The
undersigned certifies that the above statements are true to,,tt(e best of his knowledge and belief.
............. .......................................
(Signature of Owner or Agent)
JAMES. V. CALLAHAN
File # BP -2013-0767
APPLICANT/CONTACT PERSON CALLAHAN SIGN COMPANY
ADDRESS/PHONE P O Box 526 PITTSFIELD (413) 443-5931
PROPERTY LOCATION 55 DAMON RD
MAP 18D PARCEL 026 001 ZONE GI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ERECT ILLUM WALL SIGN - DODGE
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 TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P SENTED:
Approved V 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
tV
ZONING BOARD PERMIT REQUIRED UNDER: ,§ ASO ' 7' Z -7'
Finding Special Permit V Variance*
Received & Recorded at Registry of Deeds Proof Enclosed_
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Water Availability Sewer Availability
Permit from Conservation Commission
Well Water Potability Board of Health
Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
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.