39A-080 (8) City of Northampton Map 39A Lot080 Zone GB(100)/
Massachusetts Date issued 5/2/2019 0:00:00
Inspector of Buildings Permit # BP-2019-1209
Permit Fed 100.00
SIGN PERMIT
Business
Address 440 PLEASANT ST
Applicant InstallerAGNOLI SIGN CO INC
Applicant Installer Address P O BOX 1055
Work Description ILLUMINATED GROUND SIGN HAMPDEN
ZIMMERMAN
Estimated Cost $500.00
Building Department
Approval by
File#BP.2019.1209
APPLICANT/CONTACT PERSON AGNOLI SIGN CO INC
ADDRESS/PHONE P O BOX 1055 SPRINGFIELD (413)732-5111
PROPERTY LOCATION 440 PLEASANT ST
MAP 39A PARCEL 080 001 ZONE GB(1001/
THIS SECTION FOR OFFAL USE ONLY-
PERMIT APPLICATION CHECKLIST
OSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
BVilding Permit Filled u
Fee ai
TvneofConstm ion: ILLUMINATED ROUND AlPDEN ZIMMERMAN
New Construction _
Non Structural interior renovations
Addition to Existing
Accessory St Stu
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
XT FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I ORMATION PRESENTED:
Approved____Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR ___Special Permit With Site Plan
t.
Major ProjecSite Plan AND/ORT 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
�I
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.
i,!J of Nort4ampton
(� +diDsgar}tuseils 3 � `°�
\ DEPARTML,'NT OF' BUILDING INSPECTIONS
212 Main Street . Municipal Building
Ncrthamptep, MA 01060 MypP
I\11,1 t for Application for a Permit to Place or Maintain a Sign
Sidewalk Sign, Marquee or other Advertising Device
r( I egErrrtpkor e.dnen) Number ..
1 4 C V ..............
Plans must be filed with the Builtlin ns -- � Erection... 1
before a permit will be granted. Alteration................. ✓)
APR 29 7019 Repair..____ )
Repainting............ . )
ova ....( ) 4�
nFPT OF eU4n1"lr lhS....loNs II yy/(r Q
NonTttalnnlcn.maam;o FEE. l.....PAGE J.
Northampton, Mass. ...'.�tPA.aR�'.1.'t........20.19.
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
BUSINESS NAME ....i.-LQfY1�.B(.�...�.2 umooer.maln....._.........................._._.........
1. Location, Street and No. ....... .. ..hIQ.. ,.21'aSOC]�._�A.c.Q.Q:�...__........._..................
2. Owner's name ...J10S`SIP.D_._�ifYl ffl£f{(Y�)C>_Q......................................_................
3. Owner's address .a4...�a.j. C..�l PQhJ.ox..IL'o ...S�1ri.0 40.6—N.(a...Cwt
S4. Maker's name .....R� CA;....&.q ......cG. wQC. .........................J........_....._............
5. Maker's address ..l7.G.(3u>;...1QJ.5...Spilnq. .eld....1.-1.(A...f),IIGLr..l0:1`J..._......
6. Erector's name ....R. [70.1',_' >.�1Q..(t.0:_vJCJ..........._........
._............................._.
7. Erector's address . _IQJ�°j...�U... .k,.Q�d.,. .(�..O.lID1•.LOJ.�1.........
SIGN KIND OF SIGN
(Designate)
1. Sign will be (check one) illuminated ..✓.. Non-illuminated .......
2. Will sign obstruct a fire escape, window or door? .fp... 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 .a..Vdg.ins Width ..$-ft.J..ins Temporary.............
6. Face area oi!I3sq. ft. 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./....(;r:amr.(....
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 ........................ Face...Ae.y.wn..........
13. Estimated cost $...500,C0....
The undersigned certifies that the above statements are true to the best of his knowledge and belief.
(Signal re of Owner or Agent)
Page 1 of 3
THIS FORM IS PART OF THE SIGN PERMIT APPLICATION
File No.
ZONING PERMIT APPLICATION
PLEASE TYPE
R PRINT ALL INFORMATION
Cr,/
1. Name of Applicant: (1nlr Com+ ` Loy.
Atldress: �Cl 1;
11. ALL INFORMATION MUST BE COMPLETEDPERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
12, This column to be fllad in by
the Buildin De artment.
Existing Proposed Required by
Zonin
Lot Size
Frontage
Front:
Setbacks:
Side:
L: R: L: R:
Rear:
Building Height
Bldg Square
Footage
% Open Space:
(Lot area minus burg and
Paved parking)
# of Parking Spaces
#of Loading Docks
Fill: (volume S location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: NI01i Iq (i V'_ APPLICANT'S SIGNATURE (�
L..d d
V IV
c' " C
Applicant's Email Addr (requir
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
gjAl,1W!2,!� y EXISTING PROPOSED
n /
Ln�.
AGNOU SIGN COMMNY, INC.
722 WORTHINGTON STREET
SPRINGFIELD, MA 07105
TEL (413) 732-541
1 -
CUSTOMER: I uLIGHTiNG .-; ; ELECTRIC
HAMPDEN ZIMMERMAN ay - Oro• -
274TAYLOR ST 7 DESIGN SUPPLYCO
SPRINGFIELD, MA La SHOWROOM
LOCATION
HAMPDEN ZIMMERMAN
440 PLEASANT ST
NORTHAMPTON, MA
STORE#:
#000 CUT SIZE: 29 1/2" X 97 1/8"
1 5/8" MOLDING
CONTACT:
KIM LYNCH (]p
SALES PERSON: 9SH
HARRY
DESIGNER _
ELECTRIC
LANCE E L E CT R I C
ORIG DATE:04-24-19 SIDE B O ®Electrical
M Supp LY CO rs..Vf s
REV.DATE: 00-00-19
NEW LEXAN FACE FOR EXISTING ILLUMINATED SIGN
HZ ELECTRIC SUPPLY CO: TRANS CARDINAL RED & COBALT BLUE
SCALE: US LOGO: TRANS TOMATO RED & SAPPHIRE BLUE
NTS
THIS DESIGN IS THE EXCLUSIVE
PROPERTY OF AGNOU SIGN
ADMPATSUALL IGHTSSOITSSE H-MISC/HAMPDEN ZIMMERMAN-NORTHAMPTON-440 PLEASANT ST.PLT
oRREROERVED ARE HAMPDEN ZIMMERMAN NORTHAMPTON, MA-440 PLEASANT ST.CDR
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Company
Inc.
AGNOU SIGN COMMNY, INC. EXISTING PROPOSED
722 WORTHINGTON STREET
SPRINCRELD, MA 0TU5
TEL. (413) 732-51N
CUSTOMER: I
HAMPDEN ZIMMERMAN
274 TAYLOR ST
SPRINGFIELD, MA
SHOWROOM HLI DESIGN ELECTRIC SUPP LY CO
LOCATION:
HAMPDEN ZIMMERMAN
440 PLEASANT ST ,I
NORTHAMPTON, MA
STORE#:
#000
CONTACT:
KIM LYNCH CUT SIZE: 22 1/8" X 141 5/8"
SALES PERSON: 15/8" MOLDING
HARRY
144"
DESIGNER:
LANCE
INELECTRIC SUPPLY CO
ORIG DATE:04-24-19
r
REV. DATE: 00-00-19 ":T NZ
N MEl�e[trical
NEW ALUMINUM FACE
HZ ELECTRIC SUPPLY CO.: HP CARDINAL RED & SAPPHIRE BLUE
SCALE: US LOGO: HP TOMATO RED & SAPPHIRE BLUE
NTS
m
CLUSNE SIGNIITSSUSE H-MISC/HAMPDEN ZIMMERMAN-NORTHAMPTON-440 PLEASANT ST.PLT
HAMPDEN ZIMMERMAN NORTHAMPTON, MA-440 PLEASANT ST.CDR
City of Northampton Map 39A Lot080 Zone GB(100)/
Massachusetts Date issued 5/2/2019 0:00:00
Inspector of Buildings Permit # BP-2019-1210
Permit Fee$60.00
SIGN PERMIT
Business
Address 440 PLEASANT ST
Applicant InstallerAGNOLI SIGN CO INC
Applicant Installer Address P O BOX 1055
Work Description ILLUMINATED WALL SIGN HAMPDEN
ZIMMERMAN
Estimated Cost $600.00
Building Department
Approval by:
File#BP-2019-1210
APPLICANT/CONTACT PERSON AGNOLI SIGN CO INC
ADDRESS/PHONE P O BOX 1055 SPRINGFIELD (413)732.5111
PROPERTY LOCATION 440 PLEASANT ST
MAP 19A PARCEL & 001 ZONE GB000V
THIS SECTION FOR OFFICIAL USE ONLY
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONINGFORM FILLED OUT
Fce Paid , t t ,✓
Buildina Permit Filled out I
Fee Paid aT I
TvoeofConsWctiom ILLUMINATED WALL SIGN HAMPDEN ZIMMERMAN
New Construction
Non Structural igmrior renovations
Addition m Existina
Accessory Structure
Building Plans Included,
Owner/Statement or License
3 sets of Plans/Plot Plan
TIE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
FORMATION PRESENTED:
TApproved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Sim 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
TDemolition Delay
Signal=of Building Official Dam
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.
(dity of Nartfiamptun
( c
DEPARTMENT OF BU/LD/NC XSPEC77ONS
212 Main Street • Municipal Building
Northampton, MA 01060
I��rCr roK Application for a Permit to Place or Maintain a Sign
Sidewalk Sign, Marquee or other Advertising Deyi�e
(Application to be filled out in ink w t~Mn) Number If6....:.. 7. d
Plans must be filed with the Building Inspector /'+C `/C Erection..................( )
before a cennil will be aranled. RECEIVED ED Alteration.................( )
Repair..................... )
Repainting...............( )
APA 2 9 �Ofg �R��((e��moval..................( )
FE .1?!.PAGE��PLOT.......
DEPT OF aUltr4 INSPFCTIONSs
NonTNAM4bYlrlalaptpq ktass. ........20.19.
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
BUSINESS NAME ..... ...............................................
1. Location,Street and
. k.
No .......... !:�L?. ,.Q0.50q#...acee ...................................
2. Owner's name ...1'X11mptief).....ltmm(per.mean........................................................
3. Owner's address /Y�L�.i]O%..IIOL1g....+ pri(1
4. Maker's name .....t1g(.1�Q.�i..> . 6sJ.lS�.1�....W,.�InCA..............—......V.............................
5. Maker's address ...D6.(, D)L-k1 ...
�1�1L1!}..eAd,..AA..O1b1....lo5J...........
6. Erector's name .... (1f2Q��i.St�..W...,(]CJa.......................................................
7. Erector's address .. ..lJ.m...I�rj... (.tIX� .e�,.}�t�..L�.1iQl:.i.QStJ.........
SIGN J KIND OF SIGN
/ (Designate)1. Sign will be (check one) illuminated ....... Non-illuminated ..K....
2. Will sign obstruct a fire escape,window or door? ...OJ?.. Marquee ...............
3. Lower edge will be33..ft..d....ins above the public way. Projecting ..............
4. Upper edge will be 30.ft..($....ins above the public way. Roof .....................
5. Height . .ft.Jz.ins Width .. . .ft..
QL.Ins Temporary...........
6. Face area a.4..sq. ft. Wall .al.................
7. Inner edge will be ......ins from the building or pole. Sidewalk....................
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 ..(a..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 ........................ Face.,Glutnaorn....
13. Estimated cost $...Laaa.,ZO...
The undersigned certifies that the above statements are true to the best of his knowledge and belief.
C..P ............................
(Signa JoOwner 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: r
Address: Telephone: LII. - JRa -,fwl
2. Owner of Property: "Pimpaec) 01711
Address: Telephone: 413- 1.11- W IO
3. Status of Applicant:_Owner _Contract Purchaser _Lessee
J Other(explain): SjOn
a. Job Location: ryun L`.nnf1�
Parcel ID: Zoning MI Parcel# District(s)
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
A
5. Existing Use of Structure/Property: Cyrryyfc �dilU'n— 43h�� eC}I
SAnre
6. Description of Proposed Use/Work/Pro(oj��ecUOccu(pation: (Use additional sheets if necessary)
tiPL3 Olrvn'nrT[Y1 kpro a"c,r P1: :no ;' nc]1P. \"nrn.
7. Attached Plans: _ZSketch Plan she Plan Engineered/Surveyed Plans
8. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NOI KNOW YES_ IF YES,data issued:
IF YES: Was the peril 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 we0ands? NOl 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--V-1NO 1 _1
IF YES: Describe the size,type and locelion: F an- ;11 ncm nnkGC
Are there any proposed changes to,or additions of,signs intended for the�property? YES NO
IF YES: Describe the size,type and location: Oip i o Yn(,e, 2ix Ply i. V
1mn - � SFp.urrm C In�e�.
Page 2 of
11. ALL INFORMATION MUST BE COMPLETED:PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
12. Thm column to be filled m by
the Building Depanment.
Existing Proposed Required by
Zoning
Lot Size
Frontage
From:
Setbacks:
Side: L: R: L: R:
Rear:
Building Height
Bldg Square
Footage
%Open Space:
(Lot am minus bas and
Paved perking)
#of Parking Spaces
#of Loading Docks
FII(: (volume a locaaon)
13. Certification: I hereby certify that the information contained herein Is true and accurate to the best
of my knowledge.
DATE: 41 tnl1q APPLICANT'S SIGNATURE
At'T1rSY�/? [�f-1C!)61� 'a n. Cnm
Applicant's Email Addres qulred)
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
---41 CERTIFICATE OF LIABILITY INSURANCE
8/20/2018
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 INSURI IS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the pollcy(ias)must be endorsed. If SUBROGATION IS WANED,subject to
Ne 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 endorsements).
PRODUCER CONTACT
MAME.
The Dowd Agencies, LLC PHONE 41&538-Tyu PAx _
14 Bobala Road aw
Holyoke MA 01 D40 DAD LL&a:
PRODUCER !
IXaURE a AFFm01XGCOIERAGE INK/
INSURED anuar A_Fired Liber Insurance CD oresm 33588
Agnoli Sign Co., Ina IxauREae:Libe MuWal Fire lnwrence Com n 23035
722 Worthington Street
PO Box 1055 MauREac:Liberty Inwrence Caporelian 42404
Springfield MA 01101-1055 sSUI _
IxauREn E:
NSURERF:
COVERAGES CERTIFICATE NUMBER:858307518 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.
LTR ME-IXSII— PGUI NUMBER FMICY 6F PoLICYESP LYTe
A GEXEMLLNBIU T.1126101N055 aRimis 6012019 F CXOCCUXRENCE 51 om
X COMMERLIALGENERMLNBILHv
' PRE ES Eeom� SXOOD]
CWMSJMDE OOCCUR MG.Ion M crsaw
PERSONLLSADV INJURY S1.wom
OENEML AOOREG4TE
$].00.000
OEN'LAGGREGATELIMITP VESPER: gYCg1CT8-COMPIOP AOO $2MO.OM
POLICY X PRO. X LOL S
B Amman IIE UsucanY A 1126101tW3 6010015 WIM19 COMBINED SINGLE UMn
X ANYAVTO BODIYtNJ $1,0]O.ODS
BOmLY INJURY IPMpeNn) Y
SCHEDUEO ALnos BODILY INJURY IPM%tiaMa s
SCXEDULED AUI03 PROPEmY DAMAGE
X HIREDAUTCS (Remdnn f
X NON-0WNED AUTOS 5
S
C X UMSRELIA L. X aLUR TmI/Lm9 2112610MM WIMIS SGCM OCCl/RRENCE _ 55 WS _
MESS UJUR Zctr.AOE AGGREGATE SSp000
DEDUCTIBIf S
X RETEN N Sicusc S
L NTJRXERB COMPEHSATNIN WCTZ11ffi101Jme Y110018 601(1m9 X M STATU- DTH'.
AND EMPLOYERS'UIUM nY Y/X TORYLII
Arty PRCPRIETORP 'TNEI EMYE EN
L.EACH ACCIDEM $1.O .000
GFFIGE.EMaEREZLUOED4 ❑N NIA --
IMtlCMMYMXX) ELDISEASE-E_A_EMPLOYEE $10W,m0
XYM. 11ei
,, 0MT
CE9G11Pf.OF OVEONS MYw EL.OISFASE-POLIOYLIMIT f
DESCRIPTORWOPERATENSILOCAG0141VEHICLES IMe[NACORD101.Afi luU RemarFs MxedWe.lrmm Ww Ie�Wndl
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.
For Insurance Purposes Only
AVIXORISED REPIEHEMATVE
,,eMrAl
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ogee offnvestigations
M) 600 Washington Street
Boston,MA 01111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Orgmiration/individuaq: Agnoli Sign Company, Inc.
Address: 722 Worthington Street/PO Box 1055
City/State/Zip: Springfield.MA 01101-1055 Phone#: 413-732-511
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am o employer with j9si - 4. ❑ I am a general contractor and 1
employees(full and/or part-lime).• have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the arched sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y9. E) Building addition
[No workers' comp. insurance comp. insurance.'
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing alI work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12❑ Roof repairs
insurance required.]' c. 152,§I(4),and we have no ,--,/
employees [No workers' 13.[ OthcrS20�
comp. insurance required.]
'Ant applica i Ihm checks box al most also Fill out the section helow showing their workers'compensation policy information
I I kinvownets who submit this alidi vit induamost they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
4-mutualms that check this hox must touched an addilimud sheet showing the name of the sub-contractors aW state washer or not those emities have
employees If the sub-connactars Ibve employees,they must provide their workers'comp.policy number.
/am an emplgver Thal is providing workers'compensation insurance forme employees. Below is Me policy and joh site
information.
Insurance Company Name: Liberty Insurance Corporation
Policy#or Self-ins. Lie.#: WC7ZI1261014078 Expiration Date: 06/21119
Job Site Address: JI Y\P09fYN ,A. City/State/Zip: Aa o [bpm. 6/(d
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 i u ce coverage verification.
/do hereby orrlifi• der th s rel penalties of perjury thatihe infitrmatinn pronideAnhorc i.trite and currece.
Signature, _. Date: 141011.0
I
Phone#:
Official use only. lM not write in thiv area, to he completed hr ei0,or town official
City or Town: Permil/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#:
M W"ington Street
P.O.Sm 1055
Springfield,MA01101-1055 Agnoli Sign Co.
(413)732-5111 fax(413)787-2169
Memo
To: City of Northampton,MA-Building Department
From: Amanda Pfeffer
RE: Hampden Zimmerman-440 Pleasant Street-Northampton,MA
Date: 4/26/2019
Enclosed are the sign permit applications for the signage at the above location.They would like to
replace 1 side only in existing double face pylon sign and a new aluminum face in the existing wall
sign as the Showroom part of the business has closed.I have attached the sketches for the new
signage along with check#2020 in the amount of$160.00 for the permits.Can you please review and
process these applications?Please let me know if you need any additional information or have any
questions,comments.I have enclosed a self-addressed,self-stamped envelope for the permits to be
mailed to us upon completion.
Thank you.
Amanda Pfeffer
AGNOLI SIGN CO., INC.
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