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18D-040 (36) File#BP-1999-0504 APPLICANT/CONTACT PERSON Pride Convenience Inc ADDRESS/PHONE 246 Cottage St(413)584-9485 PROPERTY LOCATION 17 Damon Road(Pride Convenience) MAP 18D PARCEL 040 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOeSD REQUIRED DATE ZONING FORM FILLED OUT 3 Cl,0-t- `� Fee Paid ftt9O/, I'o2e) " Building Permit Filled out Fee Paid Type of Construction: New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Occupant Statement or License# 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. • vied as presented: -7, 2. 2 , P`e S tOL W&V S t8'ti` -�n'� /5)�I r u - 2. 'D r 1 — N^-A�l S(2.t. 1 �,�✓ ] - "Lc Special Permit and/or Site Plan Required under: § 0 PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 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. .i•-• LJ V l `J 4 Nov 18 098 r1:PT "-DING INSPECTIONS File NORTHAMPTON MA 01060 ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: r /Z CONUEN 1 eAJc /NL. 2rx _ O Address: Z-416 Co Tr4 o,C S7 5/FLO Telephone: ?' - 73 7 c7 92 2. Owner of Property: /?O13EYlr 13o.DUL Address: Zz/G C07796-E Telephone: '-// ; - 7;7- GI9Z 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): 4. Job Location: l7 0,9110N /7A Parcel Id: Zoning Map# f r /2 Parcel# 0 District(s): fit-8 (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property Comie IItMC&- STO/e- Vo-- 5 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): • C d NV t APE/JG E STO/lam l`�Ct AS (3_) ,57,�-�'�r� 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files. 8. Has a Special PermitNariance/Finding ever been issued for/on the site? NO DON'T KNOW YES X IF YES,date issued: l 1 /4/9 7 IF YES: Was the permit recorded at the Registry of Deeds? //f97 d 2 /r3Gp/006 G NO DON'T KNOW YES X' IF YES: enter Book Page and/or Document# 9. Does the site contain a brook, body of water or wetlands? NO X 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: (FORM CONTINUES ON OTHER SIDE) 10 Do any signs exist on the property? YES NO X IF YES,describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO IF YES,describe size,type and location: 11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled in by the Building Department Required Existing Proposed By Zoning Lot size 41 2 372 S. F, Frontage /SS-( Setbacks - frnnt c! ` - side L: R: L: 2 L R: /tx� - rear Building height f� Bldg Square footage %Open Space: (Lot area minus bldg 0 [ G S.F: &paved parking) # of Parking Spaces ( i # (Of Loading Docks D Fill: -(volume -& location) 13 . Certification: I hereby certify that the information contained herein a is true and accurate to the best of my knowledge. DATE: //7I - /- APPLICANT's SIGNATURE NOTE: Issuanoe of a zoning permit does not relieve an applioants burden to oomply with all zoning requirements end obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works end other applicable permit granting authorities. FILE /s i,-04' win,- v3i .4. lb • QJ r :E� �:E�'r.• Erection....._..___...........(><) tali �?�,w _ .^ Alteration___ _ .-...( ) o Rep air___..._.._7_._.._.( ) Plans must be filed witiLtlA Ay,ildjng Inspector, Repainting _..._.-..( ) before a permit will be granted, ..___-~- Removal_..._ ( ) Czt rf Xi rtIWmpt rat 01.a5 . • Application for a Permit to Place or Maintain a Sign or other Advertising Device (Application to be filled out in ink or typewritten) ELF.. . ... PAGE PLOT CMG Northampton. Mass., //v- 19 t..a To the Building Commissioner: Application for a permiterp to place or maintain a sign or other advertising device, or marquee. BUSINESS NAM E....fR.We CoMV4N(cWC-6 -Z - 1. LOCATION, STREET and No. ...../. 7 (74n'1 Dry!............ 2. Owner's name I.V iii/e..ri).L�_o2 .e.. T. c,... _...._._...._..y.......,...../�_..1.Z._.................. - .._...._._.. 3. Owner's address ...q.lP...._.. ±± .C- ...........sr Srt.e ....Q.:...1..�1. ..0...�..14.V_...._. 4. Maker's name.......1'I.. .w.... 'N.. .4.�-..ILL 5..I.a.JV 5. Maker's address la a e c 6 7 .. .. •s r• CNiCO l E E i ("' A Q/0/•3 6. Erector's name N a to Ns'r.t..! 1.1/0 S I 6 N 7. Erector's address....(.Qt .. i /1/LC./i)...._S fi CH /C O PE Lam/ m.A o. to.13 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated ..non-illuminated AA jj Marquee 2. Will sig n obstruct a fire escape, window or door? .A4.© Projecting 3. Lower edge will be.......i.....ft. ' ins. above the public way. 4. Upper edge will be..... ` ...ft. U .ins. above the public way. Roof Temporary 5. Height_..., -....ft :Q ins. Width /0 ._.ft._.._Q.._ins. 6. Face area.....3 ° sq. ft. >< 3 Si(-; 90 SF Tot,4-L � .._....._...._.........._ .._.... At_ - ' Ground_... .._....-...._...._ 7. Inner edge will be... :.4:.. from the building or pole. ,i ., Other.__....._.. 8. Outer edge will be..�...:. ..from the building or pole. ... ..._ 9. Face of building or pole is_`t`O. ..t . back from the street line. 10. Sign will prof ect......Q....ins.beyond the street line. 11. Sign will extend_._. .0 ft.._.._.._.._.ins. above the building or pole. 12. Of what material will sign be constructed? F rame..._..5I6 EL--...--- Face_..L , 13. Estimate cost. 6 o° • The undersigned certifies that the above statements are true to the best of his knowledge and belief. /f2 . , ` (Signature of Owner or Agent) NOTE:In-order that this application may be accepted, the data called for above must be set forth a • r-tr A ip,4,,,. \LNL MN rkle WALL 901 31GCf rMAL1 MN J'Xitl NO LEAD .99 ..'L/.__ MID 1.09 '"C. SUPER 1.19 1 —J DIESEL 1.19 1r-I CHANGEABLE 1e'-o --- =-n n-n -o COPY - Y-o- SUBWAV' CITGO __J CITGO SIGN ELEVATION ISOMETRIC SIGN LAYOUT SCALE: Or 8` - 1.-0` NOT TO SCALE i 1 ----------------------------J 1 I c 1 I 1 jRULDINO 1 1 1 , j 0. 1 Z j I sc j I ICANOPY I WOOn loin n ,-1LE„E S— io �aI U 0 W , i 0 L.) U lJ 0 I LETIFRS I 1 LJ T lJ CRCO LETTERS I , \\ 4 GROUND SIGN I SIGN LAYOUT SITE PLAN MOT TO]Gal • SIGN LAYOUT PLAN AND ELEVATION Prde 17 D A M O N ROAD 2411 COTTAGE STREET N O R T H A M P T O N, MA 01060 SPRINCFlELD, MA 01104 11 -06-98 Ak (413) 731-5852 C*NoSY \, k \ 1�; NQV ` �`�D r File No6P99 ` v„'JJOONING34,i-i.0MF1 PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: r /Z/ODE Co,V E�11 e NG /NL. � yl Address: Z 96 C O 7r4 G-F ST 5 PFt,O Telephone: 4ti — 73 7- GI 92 2. Owner of Property: .l?oSEitT lotOUL Address: Zi/G CO' Tr96E ST 5fckn Telephone: Z-// - 7 '7- Gti 5I _. 3. Status of Applicant: X Owner __Contract Purchaser Lessee Other(explain):_ 4. Job Location: __/ 7 9321 Q,si /?D Parcel Id: Zoning Map#__.Li 0 Parcel# Li 0 District(s):_ '✓ (TO BE FILLED IN BY THE BUILDING DEPARTMENT) Existing Use of Structure/Property CO NJcNa 4,,AkkE 3iO,Qe- VG-45 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): • 3) Co/)VE<UIEIJc STt1R6- kiCt.fS 'COAl ) (c 5 ) 6*S,te 7. Attached Plans: _____ Sketch Plan — " Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checkin with the Building Dept or Planning Department Files. 8. Has a Special PermitNariance/Finding ever been issued for/on the site? NO DON'T KNOW YES x IF YES,date issued: 11 /Sli 7.. IF YES: Was the permit recorded at the Registry of Deeds? 1cf,:N //r7/ c3/L /1-34/o66 g NO _ DON'T KNOW YES X IF YES: enter Book Page and/or Document# 9. Does the site contain a brook, body of water or wetlands? NO x 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: (FORM CONTINUES ON OTHER SIDE) 10 Do any signs exist on the property? YES NO _ IF YES, describe size, type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO " IF YES,describe size,type and location: 11 . ALL INFORMATION MUST BE COMPLETED, Or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled in by the Building Department Required Existing Proposed By Zoning Lot size . 72 F. Frontage / 1 Setbacks - front _51 - side L: R: L: R: %OOP - rear 6 7- Building height /‘ Bldg Square footage LI %Open Space: (Lot area minus Bldg 4/ j� /� bp��,ed parking) 7J I�G' 1 G �.F # of Parking Spaces f! , # rof Loading Docks d Fill: -(volume -& location) 1 rl 13 . Certification: I hereby certify that the information contained herein ( is true and accurate to the best of my knowledge. DATE: ,/- ' -9J APPLICANT'S SIGNATURE /2eX-9 a C_ • NOTE: Issuanoe of a zoning permit does not relieve an epplioent's burden to comply with ;all zoning requirements and obtain nil required permits from the Board of Health, Conservation Commission, Department of Publio Works and other applicable permit granting authorities. FILE # File#BP-1999-0503 APPLICANT/CONTACT PERSON Pride Convenience Inc ADDRESS/PHONE 246 Cottage St(413)584-9485 PROPERTY LOCATION 17 Damon Road(Pride Convenience) MAP 18D PARCEL 040 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN LOSED REQUIRED DATE ZONING FORM FILLED OUT 3 L-4 r Fee Paid /O00/;7'/5 c8' �10 ' ,etriz-v Q-to- Building Permit Filled out �� �J/ Fee Paid Type of Construction: New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: •r��+crarement or License# ;N ON THIS APPLICATION: I— presented. quired under: § ,�fr , D ZONING BOARD (� :Registry of Deeds Proof Enclosed w/ZONING BOARD OF APPEALS Registry of Deeds Proof Enclosed w/ZONING BOARD OF APPEALS t 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 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. k it 0.ZIiMlPT ' 0 4 jr's Erection...._..__._ (X) Nov I 8 1 jj ;' Alteration ( ) Repair.._.__....__. ( ) anDrlust be filed with tle Building Inspector, PW:AA NON MA01Gz+. Repainting ( ) before a permit will be granted, Removal ( ) Titg Nart4amptart, a . Application for a Permit to Place or Maintain a Sign or other Advertising Device (Application to be filled out in ink or typewritten) FEE PAGE PLOT Northampton, Mass., • fy 7-`2 19 To the Building Commissioner: • Application for a permit to place or maintain a sign or other advertising device, or marquee. BUSINESS NAME PR ID e CON V N 1 E NEE INC 1. LOCATION, STREET and No. ..... / 7 /911 d/v 2. Owner's name {R1Cz, ....�co°a.N..U .1!!.1..E...N...e., .... 'll� y,,, //►► [[ � 3. Owner's address 4... .._...c.oth.6-� sr ser�-..o, .1.)2 .....o...l.1.d..7"...... .. 4. Maker's name 11 L ._Q/. S /a 5. Maker's address 10ag Cefz'IIX ST' CHiCD/ E ) 14A 0/o/3 6. Erector's name N LU I&i L S /1/ 7. Erector's address....LQ...a...8- Tr'r fi CH ,c o,AZ.E4 h.1..A a 0/3 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated non-illuminated 2. Will sign obstruct a fire escape, window or door? Marquee v, Projecting 3. Lower edge will be....x' ft. 0 ins. above the public way. 4. Upper edge will be..:../6....ft. 1) ins. above the public way. Roof Temporary 5. Height. /3.....ft C2 ins. Width (o ft._..._U..._ins. Wall 6. Face area 7 y....sq. ft. OW V7. Inner edge will be•. f�.E ieefrom the building or pole. Other 8. Outer edge will be. aP ..iog. from the building or pole. 9. Face of building or pole back from the street line. 10. Sign will project....._....ins. beyond the street line. 11. Sign will extend......Q_..ft ....ins. above the building or pole. 12. Of what material will sign be constructed? Frame.... L .._...- •• Face..... L6,X4.M_..-......•. 13. Estimate cost. /eV en The undersigned certifies that the above statements are true to the best of his knowledge and belief. (Signature of Owner or Agent) NOTE:In order that this application may be accepted, the data called for above must be set forth CLEARLY and FULLY. 4 • 3._0. Al,„,,,,,, WALL SIGN 3'IDGt WALL SN7N rx10' WALL SIGN Yx10' NO LEAD .99 MID 1.09, .---ti 4'-0' SUPER 1.19 = DIESEL 1.19 12'-6" — _ _ CHANGEABLE / . -- — — U U B.-0 t'o' COPY 2.-0' .SU6WflV'' CITGO I G CITGO SIGN ELEVATION ISOMETRIC SIGN LAYOUT SCALE: 1/8" = 1'-0" NOT TO SCALE I ' 1 1 — ______11 1 1 1 1 1 BUILDING 1 i 1 / 1 l WALL SIGN rx10'J WALL SIGN rx10'1 WALL SIGN Yx10'J 1 i 1 1 I 1 1 1 1 1 2'X6' r1 r, CANOPY 11 r, 1 aTGO 1 I 1 1 1 LLI!Lira- 0 IDI i0l 101 0 -2•%� i i i CITGO 0 U lJ lJ 0 LETTERS LJ lJ 1 VI 2.�. 1 i CITGO Li ILNJ 1 1 \of GROUND SIGN 11 SIGN LAYOUT SITE PLAN NOT TO SCALE • SIGN LAYOUT PLAN AND ELEVATION i Pride 1 7 DAM 0 N ROAD 246 COTTAGE STREET NORTHAMPTON, MA 01060 TEL.. (4113) 737.69924 11 -06-98 FAX (413) 731-3092 1 spy t,- - (7) oottAhp,. :41 i4`r�'i: Erection.. • (>) ` ' J b . Alteration___.._......_...( ) _ Plans must be filed with the Building Inspector, al' J .,1 Repair___.._.._.__.._.( ) NOV 18 1998 L! Repainting........_......_..( ) before a permit will be granted, 4t ¢ Removal_..._ ( ) (1itgcif N�art am rtrt . ,xs5. • Application for a Permit to Place or Maintain a Sign or other Advertising Device (Application to be filled out in ink or typewritten) F'E:E7. . ... PAGE' /� EsI.OT pc Northampton, Mass., • / _� 19 l..a To the Building Commissioner: Application for a permit to place or maintain a sign or other advertising device, or marquee. BUSINESS NAME PR ID e Cory vE N1 E tsX- .nt/c • 1. LOCATION, STREET and No. ..., _/7 Pmv1 i ' ik) 2. Owner's name fR1h,1 .... QNUE..iii/..6 t)I.. ..._ -.N...C-......_...._._...._................_......................_...._...._.... 3. Owner's address ‘2c ... .(e.._..�fo'_Q't.' :4-G.-& sr....._......5 eF4...0 ...1.1 ..A._..o...1..1.0 '_...._.. 4. Maker's name.......11.. .tti ll/ I-A-..f D S /Cr 5. Maker's address 10 a 8'. 0 6 N. . .t.A T' CH/Cal�o e E 1 114 A 0../..O/3......._ _ 6. Erector's name N e tt) N4 4..41U..40 S l�i/ },� nn 7. Erector's address....l:.t?...a...� C ' �TER...._S r CH /C o PE E1 A o...t .i3 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated non-illuminated 2. Will sign obstruct a fire escape, window or door? D Marquee 3. Lower edge will be......//.....ft. 0 ins. above the public way. Projecting....._.........._ 4. Upper edge will be..... / Z....ft.....U._.....ins. above the public way. Roof 5. Height~... ....ft 0 ins. Width r Bft._.._U..._ins. Temporary 6. Face area../* r.sq. fit. '( 3 S/4'Ns . VI IF T7r-i4-(.. 11111*.. ..._...._........ _...._ 7. Inner edge will be.... . .. •from the building or pole.. Ground_...._.._.......... ...._._ 8. Outer edge will be. ... _." from the building or pole. Other.__ ......_..._ 9. Face of building or pole is_.`/0. ._ -. back from the street line. 10. Sign will prof ect.......2....ins.beyond the street line. 11. Sign will extend_. O .ft..._......_.....ins. above the building or pole. 12. Of what material will sign be constructed? Frame...Lit le__...___ Face....LE 13. Estimate cost. 3°c • The undersigned certifies that the above statements are true to the b,est of his knowledge and belief. (Signature of Owner or Agent) NOTE:In.order that this application may be accepted, tho data called for above must be set forth 3-0• 'r WALL SIGN 3'X10' TLALLSIGN 3'X10' WALL SIGN 3'%10' NO LEAD .99 MID 1.09 4 ° SUPER 1.19 I (_[= DIESEL 1.19 iv-a- "— CHANGEABLE 1e'-o' 1- 4'-0' COPY 2'-0• SUBWAY' I CITGO CITG -----_ -� I--6'-0'---1 CITGO SIGN ELEVATION ISOMETRIC SIGN LAYOUT SCALE: 1/8" = 1•-0" NOT TO SCALE I I (VI / ) .' . et4Ar' 1 BUILDING WALL SIGN 3'X10'J/ WALL SIGN 3•X10'J/ WALL SIGN 3'X10'I k \ 1 rit 1 CANOPY z'xa' r, i CITGO 4 n n n n ( LETTERS ., a la i a i O 0 —2•xa• ` 1 0 U lJ UJ D ,' 'd 1 4V•I// 1 I"`�"'•` 2'X8' 1 07G0 LETTERS 1 '\ ,—GROUND SIGN SIGN LAYOUT SITE PLAN NOT TO SCALE SIGN LAYOUT PLAN AND ELEVATION Pride 1 7 D A M O N ROAD 246 COTTAGE STREET N O R T H A M P T O N MA 01060 SPRINGFIELO, MA 01104 1 1 -0 6-9 8 TEL. (413) 737-6992 FAX (413) 731-5852 ii rrune DEC 2 81998 I J 246 Cottage St., Springfield, MA 01104-4002 Tel. 413-737-6992 • Fax 413-731-5852 f )1,e7n-.77-fl.‘ f>r i DECL....._ 28 � J 1 I . r 1 ©EFT OF HIS :1 , ,7,14s f / 1 dhacJc T' 1 1 R 1 l tV_ 12 1 f .' 'l '.. it 4 _ 1 al 1 '1 0 0 4b 8. 1 0 1 ., _ l 1 n T-- r 5 Q i4' �ANOP� W. �� 1 1 ` 1 t 1 I i O ---- KING STREET "AS—BUILT" PLAN SCALE: 1" = 40'-0" VINCENT R. DESTEFANO V.R.D. ASSOCIATES 24 EULAT DRIVE SPRINGFIELD, MA 01129 REGISTERED PROFESSIONAL ENGINEER > d '" 7TE: 12-28-98 4:_ii. VTCENT R ", VISIONS: ` AO. 22002 `" ' BUILDING SETBACK PLAN aDz p yit:ode t4,,,ti �� a 375 KING STREET 246 COTTAGE STREET h » � �"w= �i� TELI(413) 737-6992NGFIELD, MA 4 NORTHAMPTON, MA 01060 y:r., it;� ffi - FAX (413) 731-5852 0 . eitcu D -----"---------Ti--'\ Hr I. ubi DEC 2 81� .� `JEPT ' , 'ErT;GpYS a.,2-ih 6 C-ic ? I 1 Ei H __--. — i - `�-- ! 1 L4r i $l I 1 1 ito L w 1 0 Q 0 g b tL 39' 1 Z \! 0 40' 0 1 74 I CANOPY I l - -- - ----- - - - --- C � - 7 _ 2, KING STREET "AS-BUILT" PLAN SCALE: 1" a 40'-O" VINCENT R. DESTEFANO V.R.D. ASSOCIATES g31(lOS�$p� . mN r3'. Art4 i' ^" VINCEIyj R. DATE: 12-28-98oe"EEC`` BUILDING SETBACK PLAN REVISIONS: r,a. I2oaz pilde e,,'.` , ,r„�, °� 375 KING STREET . 0,P ,0"... E ' 246 COTTAGE STREET ie:fi`› .�.. -,�� NORTHAMPTON, MA 01060 SPRINGFlELD, MA 01104 "}',72; 1•,`':`� TEL (413) 737-6992 �,� � FAX (413) 731-5852 �4.c�D 1 1 1 1 .a, • . • 0.1,--if •xxf'Northampton �1'♦i yt� ; a4astxchar rite414 - ` t �'. • _11 _ =ls �' ^� �} ' DEPARTMENT OP BUILDING INSPECTIONS —=` . NOV I a l •• �� 212 Main Street • Municipal Building Northampton, Mass. 01060 r ^_I_ ;F i,St'�CT10NS Vt..d. - t,�} ;-',;,r,Pl.°11 M� •o106a WORKER'S CONITENSA.TTON•INSURANCE AIilLI)A.VTT I,• �,-vc-� e C��... ., - •-e.. p(4--c......- (li censcrJpermi ttcc) • with a principal place of business/residence at: of Y6 c.-ez eS- v /stattlap) (Pboner/) '71? 6 rj' l- • do hereby certify, under the pains and penalties of perjury, 'hal: I am an employer providing the following worker's compensation coverage for my • employees working oo this job: /17c,J . __ 4(117 n- d 000 `<f=i /—/-77 (Instuancc Company) (Policy Nurnb r) (Expiration DIM) • ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below'who have the following worker's compensation policies: - : (Name of Cone-ac.or) (lnsu aiicc Company/Policy Number) (E\-piracoe Datc) • (Name of Contractor) (Insurance CompanyiPolicy Number) (Expiration Date) • (Name of Contractor) (lnsw•ance Company/Policy Number) (Expiration Date) • (Name of Contractor) (Insura.nc Company/Policy Humber) (Expiration Date) (Laub�dditrcoal rbcct ifac ..ry to ioduck infonua:ica patoining to all comae-ors) • ( ) I am a sole proprietor and have no one worling for me. ( ) I am a home owner performing all the work myself NOTE:please be aware ttlat while hooxowlsm who=ploy persons to do maialmaaee,cooscruetioa'or repair work on a dwelling of not Daosne than throo units is which the bomoowoa rdiw or oo the grounds appurtenant aheedo arc Dot coact-ally aoasidaod to be employaa uidcr tbo woddtc?z r p—,t.4m Act(Gt.l5Zx KS)),appliatioo by a howcowocr for a Gaasc or permit may evid000c the • legal itatau of an employee under tbo Worlcola Compom.tion Ad • • I uo4cntaad the.a copy of}bis fora may bo fen ead.d to she 115•090AM col of lod.aatri.l Aoodo ate OfSo.of Irouraoo•fee tb. coverage vaifiatioo sad tbst failure to go ire cover go under soctioa 23 A of i.rOL 152 ate load to the iaeposition of crimiaal pcailtia coaitstiug pf a•Sme bf up to S 1 3OQJ)o and/or icop isoccoc t of up to one Tor and sivl1 peml'ics in the form of a W Slop octc Order Lad a frfno o(Sloo.Oo a day avian toe. . • • • • . For dcp ci ncg*ai tiao only ' . N / / Permit-Num •ber . Aeee,4____- • - - • • • _ SiY. .t oct ocusodpcimitix • t tl-n -•--�' • . • .:%t••.. „.„.:- t ii•ii..e.'.'1Q1..i41 !"t�•L-Jctiiii•t l:,•: . .. :•Ll:? oi:,'.•'f;