18D-026 (8)The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:'Builders/Contractors/Electrieians/Plumbers
Appffcatit'Infor`mation f 11, Please Print Le ibly
Name (Business/Organization/individual):
CALLAHAN SIGN, LLC
Address: 117 UNION ST P.O.BOX 744
D T TTO VT VT 7l 1AA 1 A I A '//.1 ON A/.O C(191
Uity/State/Glp: - _ _ _ _ _ ... , ... _ Phone #:
Are you an employer? Check the appropriate bog:
1. ❑X 1 am a employer with 5
4. ❑ I am a general contractor and 1
employees (full and/or part-time).*
have hired the sub -contractors
,
2. ❑ I am a sole proprietor or partnex-
listed on the attached'sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance..'
required.]
5. ❑ We are a corporation and its
3. ❑ 1 am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.) t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.)
Type of project (required):
6. ❑ New, construction
7. ❑ Remodeling
8. ❑ Demolition "
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
l3.® Other sign
Any applicant that checks box til 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.
Travelers Indemity CO
Insurance Company Name:
Policy 4 or Self -ins. Lic. 4: 6KUB-5B74571A
Job Site Address: 55 DAMON ROAD
Expiration Date: 12/19/2013
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 certify under the pains and penalties orperjury that the information provided above is true and correct
James P. Callahan 1natA/19/2013
413)V44
Official use only. Do not write in this area, to be completed by city or town official
City. or Town:
Permit/License h
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 4:
32-60592 Northampton CDJR 1 55 Damon Road I Northampton, MA 01060
CM RYS LSR'"'`'
_f DODGE Jeep RAS. DETAIL
8'-6"
6,/8„ CHR r S L E st
_�_ _..._ Y .. 21'
91/2"
L
9 SERIES CHRYSLER BADGE
Square Footage
7.03 ft2
Manufacturing Details
5" deep aluminum cabinets, silver returns
Formed .118 White Mustang w/ 1 st surface digital print
Illumination
LED internal illumination,Ventex VenBrite VL -W100
(1) VLP100-120 LED Driver - 0.5 Amps TOTAL
Colors
Black Process Black
Blue PMS 287
Silver
8'-10 v2"
12
9 SERIES CHRYSLER LETTERS
Square Footage
¢, 4.43 ft2
Manufacturing Details
Ycleep aluminum cabinets, black returns
White acrylic faces w/ 1st surface black perforated vinyl
leaving 1/8"white perimeter
Colors
Black Process Black
Silver
A
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 Riiildinn nenartment
'
EXistkig-
A A Proposed
Required by,
Zoning
Lot Size
Frontage
,
Front:
Setbacks:
Side:
L: R:
L: R:
it
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.
r,.
DATE: 2/19/2013 APPLICANT'S SIGNATURE
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 #
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: CALLAHAN SI,GN,.1LC — JAMtS P: CALLAHAN +
Address: 117 TINTON ST PTTTSFIELD, 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., Job Location: 55 DAMON ROAD NORTHAMPTON, ,MA 01000
r + Parcel ID: Zoning Map # Parcel # Di6trict(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'X12')SIGN, INSTALL 1)F.ALER NAME
LETTERS, INSTALL (1) DODGE BADGEV, INSTALL (1) JEEP BADGE, INSTALL (1)
RAM BADGE, INSTALL (1) MOPAR AND INSTALL (1) CHRYSLER BADGE
7. Attached Plans: X Sketch Plan X Site Plan Engineered/Surveyed Plans
8. Has a Special PermitNariance/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
10. Do any signs exist on the property? YES_X_ NO
IF YES: Describe the size, type and location: REMOVAL OF EXISTING SIGNAGE EX:EPT "customer
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
t
of Xnrt4ampton L `5 s�71
�t188tIf1jltSPttB
r_
C=)
7iDEPARTMENT OF BUILDING INSPECTIONS212 Main Street • Municipal Building NW S Northampton, MA 01060 INSPECTOR Application for a Permit to Place or Maintain a SignOr other Advertising Device, or Marquee �..........
J3i�
(Application to be filled out in ink or typewritten) Number . • • .
Plans must be filed with the Building Inspector_
before a permit will be granted.
To the Building Commissioner:
Erection .... .............. (X )
Alteration .................( )
Repair .....................( )
Repainting ...............( )
Removal ..................( )
FEE........ PAGE........ PLOT.......
FEBRUARY 19 ,20 1.3
Northampton, Mass . ...............................
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......I.......................
2. Owner's name ..KOA�T...S.,...T.4.MA..........................................
...............................
3. Owner's address .......
55 DAMON ROAD...........................................................................
.......
PRINCIPLEUSA INC .........................................................
4. Maker's name...................................................
2035 LAKESIDE CENTRE WAY ��250 KNOXVILLE,TN ... 37922.....
5. Maker's address ............................................... .
,
6. Erector's name.....CA..L....LAHAN ..............SIGNLLC .......... .
........................................................... .
117 UNION ST PITTSFIELD, MA 01201
7. Erector's address.................................I..............
....
SIGN KIND OF SIGN
(Designate)
1.
Sign will be (check one) illuminated x..... Non -illuminated .. • • • . •
or door.. N •••••
Marquee ...............
2.
Will sign obstruct a fire escape, window
Lower edge will be ...... ft ........ ins above the public way.
Projecting
g
3.
4.
Upper edge will be ......ft... ..... ins above the public way.
Width s total (see drawin
Roof .... ...............
g p ry
)Tem owallX
5.
Height ......ft.2.l..ins ......4....
.............
6.
7.
Face area 1L..40. ft.
Inner edge will be ......ins from the building or pole.
Ground ................
Other
8.
Outer edge will be .......ins from the building or pole.
back from the street line.
...................
g.
Face of building or pole is .......ins
10.
Sign will project .......ins beyond the street line.
above the building or pole.
11.
12.
Sign will extend .......ft .......ins
Of what material will sign be constructed? Frame .AL.UNJXV.M • • • .
• • • . Face AGUUC..........
13.
Estimated cost $.4..0.00 ............
CHRYSLER
The undersigned certifies that the above statements are true to the best off his knowledge and belief.
........................ I......
Si natUA of Owner or Agent)
f
JAMES P. CALLAHAN
File # BP -2013-0768
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 AV EP
Typeof Construction: ERECT ILLUM WALL SIGN - CHRYSLER
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 P NTED:
Approved dditional 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: § 5-�-b — 7. 6
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
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
L7-12,2,
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.