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m DEPARTMENT OF BUILDrXG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOM ER'S CONAPENSATION INSURANCE AFFIDAVIT
(li censer:/permi tire)
-vvith a principal place of business/residence at-.
(Stre—c Um ty/5tatcjZ1 P)
do hereby certify, under the pains and penalties of pegury, that:
O I am an employer providing the following worker's compensation coverage for my
employees worming on this job:
(insurance Company) (Policy Number) (Expiration Date)
(vj/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 Contactor) (Insumnc;, Company/PoLicy Number) (Exp rm ion Date)
(Flame of CoutTacior) Omamc-_ CompanyPoLicy Number) (Expiration Date)
(Name of Contractor) (lnairanc . Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(mach additional shed if noon ry to inch he iufermiiioo pc tniaing W all c�fradon)
(") r am a sole proprietor and have no one woridng for me.
( ) I am a home owner performing ail the work myself.
NOTE:please be aware that whilo hcmeoxvm Abo employ periom w do muinuaaneS c=at ctioe ar rr,pair work on a dwelling of
n.ot moco than thr"trne,in which the homeowner resides or on the grounds apVjexnarrt th t,c arc no(grncrgily oomidcmd to be
employers under the a oompc soon Act(GLI52,sa t(5))�,application by a homeowner for a license or permit may evidcace the
lepil ctaLra of an employer under the Wa$or'a Compomation Act
I undccsLaad that a oopy of this statement may be fomvxY icd to the Dcpart�of Industrial Aocidmts'moo of Irrsuramoe for tba
covaxge verificadoo and that fidure to secure covai p under soctioa 25A of MGL 152 can lord to the iMPOSAioa of-imiasl penalties
ooasistiug of a fine of up to S 1,500.00 aadlor imprison of tip to one year and civil perultiel in the form of a Step W Order and a
fmo of S 100.00 a day tgaimi tnc_
For dcpa¢tnaaatal usa only
Permit Number
MaP# Lot#
Si�taturt;of LiccnscxlPcrmittcc
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Erection.----------...........( )
Alteration........._...........
( )
Repair______...___ .( )
Plans must be filed with the Building Inspector, Repair
Repainting
before a permit will be granted, Removal-.......................
( )
Tits aaf wart amptila, jnmi i.
Application for a Permit to Place or Maintain a Sign
or other .Advertising Device
(Application to be filled out in ink or typewritten)
FFl . PAGF_ PLOT..........
Northampton, Mass.,. . ...............................:.:........4........19.........
...
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
BUSINESS NAME.... C L J..,.Cie t--G__
1. LOCATION, STREET and No. .............. ....................................._..._.._......................_....... .......................................
2. Owner's name................1 ' `t!...... 4.6t� _............................_----------....................................................................................._..........
3. Owner's address....._.........351.... .1 S ...:....................M...t� � .
4 .....................
4. Maker's name............. t? ............�:�`-................................
v`{= .....................................
5. iMaker's address.................... ........ ............................
6. Erector's name.__.._ ...... _......__._. .................................
7. L'rector s adaz-ess. .._..... _........ ............. ...........__._..........._.............._...._.........................................._......
................................
SIGN KIND OF SIGN
(DC51�'71a t(.)
L Sign will be, (check one) illuminated..................non-illuminated......_.
2. Will sign obstruct fire escape, window or door?...1�..r._.
Marquee......................................
.
3. Lower edge will be....._...........ft. ..................ins. above th Projecting................................ .
e ;� y.
4. Upper edge will be....__..........ft. ..................ins. above the
5. Height_.................ft. f/-� Temporary.................................
..................zns. Width..........._.....ft---.�!�_.....ins. //
6. Face areaJ.VA2. 7 s q. ft. wall.................V ................
Ground............................._..........
7. Inner edge will be....... -`...ins from the building or pole.
Other......................._...._...............
8. Outer edge will be...............ins. from the building or pole.
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 pole.
12. Of what material will sign be constructed? Frame....._..�'`�°3'�.-...-.......... Face.............��_.
13. Estimate cost..��11�!`.a
The,undersigned certifies that the above statements are true to the
best of his knowledge and belief.
(Signature of Owner or Agent)
NOTE I11 order that this application may be accepted, the data called for above must be set forth
CLEARLY and FULLY.
c
10. Do any signs ebst on the property? YES v/' NO
IF YES,describe size,type and location:_
Are there any proposed changes to or additions of signs intended for the property?YES V NO
IF YE/S',describe size,type and location:_ 1J�% 22� ���� SkCiy
11. ALL INFORMATION MUST BE COMPLE'T'ED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This colama to be filled in
by the Bailding Department
Required I
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L• R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&pax,ed parking)
# of -Parking spaces
f 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.
DAVE: q'w '�c APPLICANT's SIGNATURE_
NOTE: issuanoe of a zoning permit does not relieve an applioant's burden to oom wlt ~
zoning requirements and obtain all required PIY Ip .pll
q permits from the Board of Health. Conservation
Commission. Department of Publio Works and other applioeble permit granting authorities.
FILE #
File No. � r
ZONING PEST APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: � �-
Address: �L C�r'z S�• i�cr�k ^1�`Z"� _Telephone: GV y�f
2. Owner of Property:
Address: 3S1 �� 5 -i ST +3L2!Lt QyJ Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): w1(9rJ t r?,2�CA`ZT'_
4. Job Location: 3 l
Parcel Id: Zoning Map# a Parcel#,1 er*'C District(s): �
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property Dr �—�C 5 / A,c�✓ - Z
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
0
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 Permit/Variance/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? 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:
(FORM CONTINUES ON OTHER SIDE)
File#BP-1999-0184
APPLICANT/CONTACT PERSON Porcupine Signs
ADDRESS/PHONE 2C Conz St (413)584-4501
PROPERTY LOCATION 351 PLEASANT ST
MAP 32C PARCEL 140 ZONE &—5
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid — lwaZ4
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 LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
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
rd�d� oard of Health Well Water Potability Board of Health
Permit from Consery io
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.
Department: Reference No: 13P-1999-0184
Building, Electrical & Mechanical Permits
.........................................................................................
Fee Type: Receipt No:
Sign
......................................................................................... R1:C-1999-000377
Paid By: Paidi'n'F'uT10'n:.....
Porcupine Signs
................................................................................... Fri Aug 14,1998
.. . ...... ......
ceived By: .Check. . .No:...................
Linda Lapointe
1634
......................................
DEPARTMENT'S COPY Amount: $20.00
......................
DEPARTMEN"I' FILE COPY 351 PLEASANT ST
CITY OF NORTHAMPTON
BUILDING PERMIT
Owner's pulling their own permits or dealing with unregistered contractors for applicable work do
not have access to Guaranty Fund(MGL 142A)
Issued: Permit No: Inspector: Tracking No.: Fee:
BP-1999-0184 $20.00
GIS 4: Map Block: Lot: Address: Zoning: Use Group: Lot Size:
10142 32C 140 001 351 PLEASANT ST GB 0
Contractor: License Type: Insurance:
Porcupine Signs
Address: License No.: Insurance No.:
2C Conz St
LtE State: Zip Code: Phone:
NORTHAMPTON MA 01060 (413) 584-4501
Pro iect No: Category of Work: Const. Class: Cost Estimate:
JS-1999-0321 signs $340.00
Description of Work:
FRONT WALL SIGN
GeoTMS@)1997 Des Lauriers&Associates,Inc. Signature: