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23B-046 (276) City of Northampton Map 23B Lot046 Zone M(99)/WP(21)/URB(1)i Massachusetts Date issued 1/24/2020 0:00:00 Inspector of Buildings Permit # BP-2020-0816 Permit Fee$100.00 SIGN PERMIT Business Address 30 LOCUST ST Applicant InstallerAGNOLI SIGN CO INC Applicant Installer Address P O BOX 1055 Work Description ILLUMINATED MONUMENT SIGN COOLEY DICKINSON Estimated Cost $3200.00 Building Department Approval by: 6X" City of Northampton Map 23B Lot046 Zone M(99)/WP(21)/URB(1)/ Massachusetts Date issued 1/24/2020 0:00:00 Inspector of Buildings Permit #.BP-2020-0817 Permit Fee$100.00 SIGN PERMIT Business Address 30 LOCUST ST Applicant InstallerAGNOLI SIGN CO INC Applicant Installer Address P O BOX 1055 Work Description NON-ILLUMINATED MONUMENT SIGN -- COOLEY DICKINSON Estimated Cost $800.00 Buildinp, Department Approval by: File# BP-2020-0816 APPLICANT/CONTACT PERSON AGNOLI SIGN CO INC ADDRESS/PHONE P O BOX 1055 SPRINGFIELD (413)732-5111 PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: ILLUMINATED MONUMEN N-COOLEY DICKINSON New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan TH OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 1 ORMATION PRESENTED: V/ 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 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. Coity of Xvrrt4an-t tvn - s Rttssttrlfusriis �'° Jw_ <<G DEPARTMENT OF BUILDING INSPECTIONS s 212 Main Street • Municipal Building V gyp Northampton, MA 01060 INSPECTOR Application for a Permit to Place or Maintain a Sign Sidewalk Sign, ,Marquee or other Advertising Devic qq(Applic ionto t in ink or typewritten) Number ..C. . .. .. Plans must be filed with the Building Inspector Erection...................( J/ before a permit will be granted. Alteration.................( ) Repair.....................( ) JAN 16 Df Repainting............... 20 R mova0 I........ ........E. ��P (( )PN E �.PAGE ... LOT...) 7(/ ORTAMOOt1SpCNFTI N To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device, or marquee. BUSINESS NAME ....1.,.//�WK4..... ;.CX�.�` G�............................................................ 1. Location, Street and N{{o. .... ...Uac Dc.�C....s�xpe.e ............................................... 2. Owner's name ........1..0.o1ei.... :►C�.tC �....t X41 .01..................................... 3. Owner's address....30....�-4CtaS 4. Maker's name ........�. (���.... ��n.....4A.....(. ........................................................ 5. Maker's address 6. Erector's name ........ .......CODA........................................................ 7. Erector's address... O.Q.R ...1QJ`J..... f.tn }.;.e�C�...1`(��t...Q�1Q1 ..�.QJ.�....... SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated Non-illuminated ....... 2. Will sign obstruct a fire esc:ane, window or door? ...rte.. Marquee ............... 3. Lower edge will be . ..ft..:. *.ins above the public way. Projecting .............. 4. Upper edge will be ..Lft..I.....ins above the public way. Roof ..................... 5. Height .U..ft..l...ins Width .q...ft..@..ins Temporary............. 6. Face area .i.il:SZsq. ft.(dcoC,e S tded) Wall ..................... 7. Inner edge will be ......ins from the building or pole. Sidewalk.................... 8. Outer edge will be .......ins from the building or pole. Other.....*1.................. 9. Face of building orole is .! .i.1Rs back from the street line. 10. Sign will project ..0..ins beyond the street line. 11. Sign will extend ...(Ji..ft .......ins above the building or pole. 12. Of what material will sign be constructed? Frame .A�-!?.!?�:t��? ...., Face...\4XCn........... 13. Estimated cost $.. ,.C�..... The undersigned certifies that the above statements are true to the best of his knowledge and belief. - ................................. (Signature of Owner or Agent) 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: AQnm, ),�C(� On \m Address: o X �oe -) O(iOQ_'P� 6Y1 G Telephone: 23a 2 a ' 5 1 2. Owner of Property: 1r ei ICk'n9s T Address: Q 1.._b(,XS CV_k�Or C)koM QTelephone: 3. Status of Applicant:_Owner _Contract Purchaser _Lessee ✓Other(explain): ,Son 1ns�o\ler 4. Job Location: Areek Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: AC6c);\Q\ 6. Description of Proposed Use/Work/Project/Occupation:(Use additional sheets if necessary) 1RelL Q e> % A'cQ 6ac )hte 5-6e6 -i\1 t�cm�ncPd =o m pn* 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans 8. Has a Special Perm itNariance/Finding 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? NODON'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'mpe ,-Dft coc� pvoO \cy(k6( .1 OnA Ori ��� �m.nn�PC� IYXK��M QCI Are there any proposed changes to,or additions of,signs intended for the property? YES v NO IF YES: Describe the size,type and location:�e 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: 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. DATE: +,$1 &);�)0 APPLICANT'S SIGNATURE I orr4 C,4 CZ.P ncc�ol� FOCI (� Applicant's Email Ad&ess(rered) 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 i Acs or CERTIFICATE OF LIABILITY INSURANCE76/21/2019 E(MM/DD/YYYY) `,.., 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 ± NAME: Linda Alstede The Dowd Agencies, LLC PHONE FAX 14 Bobala Road UVC,No,Eltrl:413-538-7444_ ____ /AIC,No): EMAIL Holyoke MA 01040 ADDRESS: lalstede(§dowd.com PRODUCER CUSTOMER ID a: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Sentry Insurance 249813 Agnoli Sign Co., Inc. 722 Worthington Street INSURER 8: PO Box 1055 INSURER C: Springfield MA 01101-1055 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1398892768 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. 1NSR TYPE OF INSURANCE -AOOCSUBR POLICY EFF ! POLICY EXP LIMITS LTR POLICY NUMBER MM/D MMI YY A GENERAL LIABILITY A0130589-04 6/21/2019 6/21/2020 EACH OCCURRENCE $i,000,000--- X ,000,000_ _X COMMERCIAL GENERAL LIABILITY -DIWWAGE TO RENTED I PREMISES(Ea occurrencel_-- $500000 _ i 1 CLAIMS-MADE r_X OCCUR MED EXP ' _--- (Any one arson $5�000,—__. PERSONAL&ADV INJURY $1.000,000 GENERAL AGGREGATE $3.00_0,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2.000,000 POLICY 1 X PRO- X I LOC $ A AUTOMOBILE LIABILITY A0130589.01 6/2112019 6/21/2020 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ".X ANY AUTO BODILY INJURY(Per person) $ _—-_- ALL OWNED AUTOS BODILY INJURY(Per accdent) $ SCHEDULEDAUTOS X PROPERTY DAMAGE $ HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ $ A X ` UMBRELLA LIAR X OCCUR A0130509-06 6/21/2019 6/21/2020 EACH OCCURRENCE _$_5.000 000_ • EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION A0130589-05 6/21/2019 6/2112020 X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN --- - ANY PROPRIETORIPARTNERIEXECUTIVE❑ E.L.EACH ACCIDENT $1000, 000 OFFICER/MEMBER EXCLUDED? N NIA — - --- (Mandatory In NH) E L DISEASE-EA EMPLOYEE $1 000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CBRE GWS LLC.and TD Bank,NA listed as additional insured for General Liability as per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. �. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION, All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD '\ The C'omtnonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WiTH THE PERMITTiNG AUTHORITY. AlMlictint Information Please Print Legibly Business/Organization Name:Agnoli Sign Company, Inc. Address: 722 Worthington Street /PO Box 1055 City/State/Zip:Springfield, MA 01101-1055 phone #:413-732-5111 Are you an employer?Check the appropriate box: Business Type(required): .Q I am a employer with ___ employees(full and/ S. ❑Retail or par(-lime).* 6. ❑RestaurantiBariEating Establishment 2.❑ i am a sole proprietor or partnership and have no 7. E]Office ancVor Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacluring no employees. [No workers'comp, insurance required]* 4.[] We are a non-pi-olit organization,staffed by volunteers. 1 L❑ Health Cary with no employees. [No workers' comp, insurance req] 1',❑ Other *Any applicant that checks box rtt must also till out lltc section hciow showing their workcrs'compensation.policy information °"'If the corporate officers have cxcotpted tlicrosdvcs,bin the corporation has olhcr employees•a work ens'compensation policy is required and stich an organization shou.d check box i;I. 1 aut an employer that is providing workers'c•ompensati,rr i�u+errrnre Jur my etnpinvees. Beloit,is the policy inlormation. Insurance Company blame: Sentry Insurance Insurer's Address: PO Box 8048 City/SlateiZip: Stevens Point, Wi 54481-8048 Policy it or Self-ins. Lie. 4 A0130589-05 Fxpiration gate:06/21/20 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requires(under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ora tine up to`d 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$250.00a day against the violator. Be advised that it copy of this statement may be forwarded to the Office of investigations ofthe D for itis fns coverage veritialliun, i do hereby certify, a ulcv Il • zeins and penalties of perjuty that the iglbrmatiou provided above is true and correct. Si mature: �' '-� I)tte P!, lie#:413-73/-5111 Official use only. Do not write its this area, to be completed by city or town ollicial. - City or'I'own: Permit/License# Issuing;Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office ti.Other Contact Person:— Phone 0: www mass gmAin I . Punipanv01i REMOVE RED FROM EXISTING MOLDINGS & SIDE AGNOLI SIGN COMMNY,INC. 722 V"THINCTCNJ STREET ox SPRINGFIELD,MA OM TEL(413)732—STrl a?' V.O.: 70" X 107" tosrlTA CUSTOMER: COOLEY DICINSON ' 30 LOCUST ST. 1101, Z?5 c \ NORTHAMPTON,MA 0D f North Entrance f Main Entrance � COOLEY DICKINSO N LOCATION: MASSACHUSETTS GENERAL HOSPITAL AFFILIATE 7" COOLEY DICKINSON 30 LOCUST ST � *- EMERGENCY � NORTHAMPTON,MA M r z Go *- North Entrance STORE#: #000 `° PROPOSED <- Main Entrance CONTACT: JULIA SORENSON , Nent Care _ NSONS7+EMERGENCY ALES PERSON: S GENERIC HOSPITAL RFFILIATE t / HARRY J■ DESIGNER: 2 NEW LEXAN FACES FOR EXISTING ILLUMINATED SIGN +North LANCE TRANS BLACK, OLYMPIC BLUE, ORANGE & RED - - te ORIG DATE: 11-20-19 Urgent—Care REV.DATE: 12-09-19LRV r 01-06-20LRV SCALE: NTS THIS DESIGN IS THE EXCLUSIVE PROPERTY OF AGNOU SIGN COMPANY AND ALL RIGHT INCORPORATEDSS CMISC/COOLEY DICKINSON-NORTHAMPTON, MA-30 LOCUST ST,PLT OR REPRODUCTION N ARE RCOOLEY DICKINSON-NORTHAMPTON, MA-30 LOCUST ST.CDR File#BP-2020-0817 APPLICANT/CONTACT PERSON AGNOLI SIGN CO INC ADDRESS/PHONE P O BOX 1055 SPRINGFIELD (413)732-5111 PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOS EQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: NON-ILLUMINATED MONUMENT SI - OLEY DICKINSON 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: ,./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 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. City of Nuri ttm hnn s �tRttssttrhusrifs �}• �- '�. w � v.. DEPARTMENT OF BUILDING IMSPF,CT10AIS 212 Main Street • Municipal Building Northampton, MA 01060 rhe o INSPECTOR Application for a Permit to Place or Maintain a Sign Sidewalk Sign, Marquee or other Advertising Device (Application to ut in Ink or typewritten) Number ..........%.-/.......... Plans must be filed with the Building Inspector /� Erection..................( before a permit will be granted. V f`1 Alteration.................( ) V Repair.....................( ) JAN Repainting...............( ) 6 020 Removal.......... .. ...( ) QFP ((�� 11 NO�F%J EE.�,`''.PAGEp.�PLOT...� RTNgM ro IN,Pp To the Building Commissioner: , Application for a permit to place or maintain a sign or other advertising device, or marquee.//�� BUSINESS NAME ....1.. dg.4 ... i. 'Y��.R�Q�............................................................ 1. Location, Street and No. ....2--C.)...L�QCL;,��....`.�,k1cl°.9_�............................................... 2. Owner's name ........� ok. . �.... AcY.>cid.... 'V`�~�n\..................................... 3. Owner's address ....3D.... 4. Maker's name ........�.. (1G1,.... ���..... -A...... ........................................................ 5. Maker's address .�U. X..1Q5`... rif� 3,.elCt...m ...C.?�.�Q�'...���.�........... 6. Erector's name ........ OD\i.....ST........UA........................................................ 9 84 7. Erector's address ...�a.Q��??S...IQS..... s.!�?. }:�Q�_.ma...Q►11J� ..�.4J.�...... SIGN KIND OF SIGN 1. Sign will be (check one) illuminated ....... Non-illuminated ....... (Designate) 2. Will sign obstruct a fire escape, window or door? ... Marquee ............... 3. Lower edge will be .3..ft........ins above the public way. Projecting .............. 4. Upper edge will be .S ..ft.. ...ins above the public way. Roof ..................... 5. Height .a.1.fta...ins Width &.ft.9...ins Temporary............. 6. Face area��o,b.sq. ft. (doub►e 5lded-V-5hcoe) Wall ..................... 7. Inner edge will be ......ins from the building or pole. Sidewalk.................... 8. Outer edge will be .......ins from the building or pole. Other.....v................. 9. Face of building or ole is J�..A back from the street line. 10. Sign will project ... ins beyond the street line. 11. Sign will extend .. . .ft .......ins above the building or pole. � 12. Of what material will sign be constructed? Frame ...CAkOM.Ickn x ..., Face..&bC6........ 13. Estimated cost $.....� ?,CC0.. The undersigned certifies that the above statements are true to thp best of his knowledge and belief. ............. . ..... ...... ............................... (Signature of Owner or Agent) 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: �Qnm' ) Cc)- \o Address: rJ ` p �3�F) `\ \ t Tele hone: �.�' 2. Owner of Property: Address: AO La(c)s� 112�k• �10%A()(`0cCkj0 9QTelephone: 3. Status of Applicant:_Owner _Contract Purchaser _Lessee Other(explain): 'Ci"q% \f ka k 4\\ec 4. Job Location:— lam Locc6k "?tCeek Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: Sp 6. Description of Proposed Use/Work/Project/Occupation:(Use additional sheets if necessary) e e � � 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans 8. Has a Special Perm itNariance/Find ing 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__Z 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\axey P CaA 00Mkc ko'c'I C3[� CC)C\ hca ��\��mg��P[l MCX�utnf 113 Are there any proposed changes to,or additions of,signs intended for the property? YES�v NO IF YES Describe the size,type and location: Y'e "rc c 2 V- n��(—? �J ) 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 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: (KI c-1 0 APPLICANT'S SIGNATURE 1 rr�l P. G4fyA" olm I t'-(;tlol; SlG)- Um Applicant's Email Ads ess(re red) � 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 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/21/2019 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 NAME: Linda Alstede The Dowd Agencies, LLC PHONE 14 Bobala Road (AIC,No,EXU:413-538-7444 (Arc,No) _ Holyoke MA 01040 ADDRESS: laistede@dowd.com PRODUCER CUSTOMER ID III . INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Sentry Insurance 24988 Agnoli Sign Co., Inc. 722 Worthington Street INSURERS: PO Box 1055 INSURER C: Springfield MA 01101-1055 INSURER D: INSURER E: ' INSURER F: COVERAGES CERTIFICATE NUMBER: 1398892768 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. IXP LTR TYPE OF INSURANCE 'ADRL'5UBR POLICY NUMBER MM DDJYEYYY McWODmYY LIMITS LTR A GENERAL LIABILITY A013O58'.3-04 6121.12019 6121./2020 !EACH OCCURRENCE $1,C00 000 DAMAGE YOAENYED .. I X COMMERCIAL GENERAL LIABILITY i PREMISES(Fa occurronco; ,$500000 CLAIMS-MADE X !OCCUR MEO EXP(Any one peso,) $5 000 j PERSONAL&ADV iN1URY $1 coo 000 t GENERAL AGGREGATE $B.C6C'i0J r -j ._ 1 GENT AGGREGATE LIMIT APPLIES PER. ISL PRODUCTS-COMPIOP AGG $2 COC 00 I I POLICY[X !PRO• 1 X 1 LOC +$ A j AUTOMOBILE LIABILITY ! A0130589-01 6/21/2019 6/2112020 COMBINED SINGLE LIMIT $1,000,000 I - (Ea accident) X ANY AUTO - -- BODILY INJURY(Per person) $ ALL OWNED AUTOS - --- - BODILY INJURY(Per accident) $ SCHEDULED AUTOS ---� j PROPERTY DAMAGE $ X HIREO AUTOS (Per accident) X I NON-OWNED AUTOS - _. $ --- - $ A X UMBRELLALIABf X OCCUR i A0130589-06 6121/2019 6/21/2020 1 EACH OCCURRENCE EXCESS LIAB CLAIMS MADEi I AGGREGATE } 5,GCC,000 DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION A0'..30589-05 6/21/2019 I 6/21/2020 X WC STATU ( 0TH AND EMPLOYERS'LIABILITY ---110RY.LI(1�(T$ ;.--EE.. ...-- YIN ANY PROPRIETORIPARTNERJEXECUTIVE ! E L EACH ACCIDENT i$1,000 000 OFFICER/MEMBER EXCLUDED? I(Mandatory in NH) j E L DISEASE.-EA EMPLOYEE!$1,000,000 it yes,describo under DESCRIPTION OF OPERATIONS belo I E L DISEASE-POLICY LIMIT .$ DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space is required) CBRE GWS LLC.and TD Bank,NA listed as additional insured for General Liability as per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. �. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts t -- Department of Industrial Accidents r+ 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print L.eaiblY Business/Organization Name: Agnoli Sign Company, Inc. Address: 722 Worthington Street /PO Box 1055 City/State,t7_ip: Springfield, MA 01101-1055 phone #:413-732-5111 Are you an employer?Check the appropriate box: Business Type(required): 1.0 1 am a employer with employees(full and/ 5. ❑Retail or par(-time).* 6. n Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7, ❑Office and,'or Sales(incl. real estate, auto,etc.) employees working for the in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its of'Ctcers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers'comp. insurance required]* 4.❑ We are a non-prolit organization,staffed by volunteers, 1 I.[] Health Care with no employees. [No workers' comp. insurance req] 1'?-•❑ Other *Any applicant ilial cheeks box#1 must also fill out the section hciow showing their workers'compensation policy in urmation *.*If the corporate officer,have exempted tlicmaclvcs,bat the corporation has other employees-1 workers'compcnsalij m policy is required and such an organization shou.d ahcck box t;I. /asr an entp/coyer that is providiu�tcurkcrs`compettsatintr lire«rrrnrc jor rn� eurpinpec>s. Relow is the polio}'irt%trroratioll, insurance Company Name. Sentry Insurance Insurer's Address: PO Box 8048 City%SlalciZip; Stevens Point, Wi 54481-8048 Policy it'or Self-ins. Lie. 4 A0130589-05 Expiration Dhte:06/21/20 Attach a copy of the workers' compensation policy declaration page(showing the policy dumber and expiration date). Failure to secure coverage as requited under Section 25A of N4131,c. 152 can lead to the impwition of criminal penalties ora tine up to$1,500.()0 and/or one-year imprisonment,as well as civil penalties in the form of a SrT OP WORK ORDER and a tine Of up to$25().00 a day against the violator. Be advised that a copy of this s(alemcnt may, be forwarded to the Office of Investigations of the UI A for itis nce covertI;c verification. !do hereby eer0y,, if uler tl tthts and penalties of'perjuty that the infornuctioa provided above is tare and correct. ranu e: Mile: r 413-73 -5111 Ojjic•ial rose onit,. Do not write in this area, to be completed by city or town oJficiul. _ City or'Ibwn; Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City!Town Clerk 4. Licensing Board 5l Selectmen's Office b.Other Contact Person; Phone 4:- Www rrrc;s L om;dm gnI oli REAR VIEW lgn (,omp any nc. we I AGNOU SIGN COMPANY,INC. 722 WORTHINGTON STREET I SPRINGFIELD,MA 01105 TEL(413)732-5111 45 1/2" CUSTOMER, COOLEY DICKINS COOLEY DICKINSON MASSACHUSETTS GENERAL HOSPITAL AFFILIATE 30 LOCUST ST.NORTHAMPTON,MA V777-r + Main Entrance SIGN 2 N N N • - nt Care LOCATION Women's COOLEY DICKINSON Midwifery 30 LOCUST ST REMOVE EXISTING SIGN FACES NORTHAMPTON,MA I 45 1/2" ,�STORE# map #000 COOLEY DICKINS Ty �� "�" T MASSACHUSETTS GENERAL HOSPITAL AFFILIATE- main Entrance CONTACT: N .Q , _ nt care JULIA SORENSON r SIGN 1 N LO N N Midwifery SALES PERSON: + Urgent CareMidwifery HARRY Women's DESIGNER. Midwifery LANCE Lj ORIG DATE: 12-02-19 REV.DATE: 12-09-19LRV 2 DIBOND PANELS HP OLYMPIC BLUE, NIMBUS GREY, TOMATO RED & LT ORANGE VINYL EXISTING PROPOSED SCALE: NTS THIS DESIGN IS THE EXCLUSIVE PROPERTY OF AGNOU SIGN TED wALLRI�, ITS USSE CMISC/COOLEY DICKINSON-NORTHAMPTON, MA-30 LOCUST ST.PLT OR REPRESERV DD ARECOOLEY DICKINSON-NORTHAMPTON, MA-30 LOCUST ST.CDR