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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 x*rs;+r .�. t.�sr �...a'.a# ,aixi.�'.4�,,; -•.:���.:ms.`f.',rer+or,magPs. .� .,•a'.a�� �Heir'tuwsr�*tn!Aeu+rs.�.etww.+►.+c>t.- : �, r =a�.c��a.: aes:wots¢4.:.s.'... a'.w.�P, a;rs,.z,r.�--� .., '• :xr,.ueaRNx.�rw.r-z:;�+- , ...u� �yi,.wf�kxy 's A . Y .a. Z' :. f 4 % t. Aw yy y ! CC f y u P } j ,T, x7 • w'epX ;r -�+- .... t y .r' r P s yq Cr .-. r x _ h rpiw ♦.-_% ��. .' _ : o 'H. t�.W ol} . . .5�>I .. Wo , A. LMe a. h� ... - F1M1t ..,. v „ gnoli & Y 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. 1