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18D-028 (6) File # 15 APPLICANT/CONTACT PERSON:SIGN DESIGN 170 LIBERTY ST BROCKTON, MA 02301 PROPERTY LOCATION 8 NORTH KING ST MAP:LOT 18D-028-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $30.00 Type of Construction: MOVE SIGN BACK 10 FEET New Construction Non Structural 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 IN 'ORMATION PRESENTED: 14' Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ iC '- Intermediate Project: Site Plan AND/OR Special Penn it With Site Plan 5enieb Major Project: Site Plan AND/OR Special With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded a t Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Ava ilability 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 S 93/Q.) ature of BuildingOfficial I I 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. Citif5 3g c� File No. . / ZON4NG PERMIT APPLICATION (§1 o.2) Please type or print all information and return this form to the Building Inspector's Office-with the $30 filing fee (check or money order)payable to the City of Northampton NI`co(t hp rd y- c ben 1. Name of Applicant: (:)i Jn best Get') . 5`5h `��� ' Address: 110 L.t be— it Si--, ).,,n i ? on :-�bl ' Y r�CA -Iv Telephone: �U�' j�� -c/���1y x ao 2. Owner of Property: Gi VG r CX /- Address: l,'r'('4h `..fY)PiD ( Telephone: 'rl -7 - qg —175C� (n s R,e r 3. Status of Applicant: Owner Contract Purchaser '— Lessee Other (explain) 4. Job Location: ' K,t rl 9 Si Parcel Id: Zoning Map# Parcel# District(s): In Elm Street District In Central Business District (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: 1 Yl SLL (_ eciLi/1 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): e d� I `� r r (1 `I e \1 1 S 1 rl S -. ba cA_-. 1 O beC 45EX c 2 5~krop4. LJidevl^ln3 rojp iL 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans 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) W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 10. Do any signs exist on the property? YES ✓ NO IF YES, describe size, type and location: 4+1Q eV.I s -1("VQ S(3)Th 1S 1 n 4{�, �r r) 7 "— e rz10-e4_. a < hoiun >or \a ov'i- ) Ck_ 0rn L- 1 h `- -1n e imp uo I o ca-h 1n O C The -t' i 5 q s ,5 r) Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: 11. Will the construction activity disturb (clearing, grading, excavation, or filling) over y'acre or is it part of a common plan of development that will disturb over 1 acre? YES NO ,/ IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building Department EXISTING PROPOSED REQUIRED BY ZONING Lot Size Frontage Setbacks Front !'vt P D m '�` ) ,(.4 , C` \L Side L: R: I t C) L: R: L: R: Rear 011+11 fond I S Iden.pot • Building Height Building Square Footage % Open Space: (lot area minus building & 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: /I '01‘ Applicant's Signature Ike a LC d\10_140 (' 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, Historic and Architectural Boards, Department of Public Works and other applicable permit granting authorities. W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 Commonwealth of Massachusetts : Division of Professional Licensure Board of Building Regulations and Standards ConstructfonlSj)'pervisor CS-068112 i Expires:08/21/2022 RALPH R FERRIGNO,JR�, — 81 JOHNSON'FARM ROAD NEWBURY NH.03255 t O1Ss.I tO- 4 x a g► Commissioner deb n. Vol 6^.7 Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl AP!7massA9C7T assachusetts Department of Transportation ighway Division ASSIGNMENT OF RELOCATION PAYMENT Claimant: Flavorland Realty Trust City/Town: Northampton Parcel No: 23-I.23-I-C.23-HS-4.23-PU E-l.23-TE-6.23-TE-9 Project: 608236 F.A.P#:N/F/A Flavorland Realty Trust intending to claim a Relocation Payment,requests and authorizes MassDOT,to pay on the Claimant's behalf,to Sign Design Inc.,the Assignee full payment of the claim in the amount of $13 950.00 The specific amount payable is to be determined by MassDOT in accordance with prevailing regulations governing Relocation Payments after satisfactory performance of the work,and upon receipt of an invoice from the Assignee.The invoice will be itemized showing type of work performed and material costs. Claimant shall certify that the work has been satisfactorily completed. Any obligation to the Assignee in excess of the amount approved by MassDOT will become the sole responsibility of the Claimant. The Claimant and Assignee acknowledge that MassDOT has reserved the right to deny a Relocation Payment to the Claimant or to his Assignee. The Claimant and Assignee further acknowledge that the Department does not guarantee the amount or time of payment under this agreement. The Claimant and the Assignee certify that neither has given or promised additional undisclosed payment, rebate,bonus,or commission and neither will receive such undisclosed payment,rebate,bonus or commission as an inducement for the consummation of this transaction. The Claimant and the Assignee understand that the selection of the Assignee and the acceptance of the materials used and the work performed is the sole responsibility of the Claimant and that MassDOT is not responsible for the performance or quality of material and workmanship. The Claimant and Assignee authorize MassDOT to issue any and all payments to the Assignee. The Claimant authorizes MassDOT to deduct any payment under this assignment from the total Relocation Payment now due or hereafter to become due from the Commonwealth of Massachusetts, in connection with this claim only, and the Claimant and the Assignee agree to execute forms as may be necessary to qualify for such payment. WITNESS our hands and seals this ( day of (4)6•-4(--- 20 � Claimant's Signature&Title Date u / 7 /3 I Assignee's Signature&Title Date (EXHIBIT# 17-27 Revised 1/18/11) The Commonwealth of Massachusetts Department of Industrial Accidents r id=—_ Office of In vestigations �l—" 1 Congress Street, Suite 100 F _u_= Boston, MA 02114-2017 two - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Sign Design, Inc. Name (Business/Organization/Individual): Address:170 Liberty Street City/State/Zip: Brockton, MA 02301 Phone#:508-580-0094 Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 65 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL YP 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no q ] employees. [No workers' 13.� Other Signs comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 3 Q-A e G i \'Q l Yl S L A YO,-f( e- . Policy#or Self-ins. Lic.#:WC 9080309 • . Expiration Date;01/21/2022 Job Site Address: S N) Y 4-v) S4 Si- ' City/State/Zip: najrha 1'h06Y1 r- 4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date 1U�U 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 insurance coverage verification. I do hereby certify under� �� �� ""the pains and pen, , perjury that the information provided above is true and correct. Signature: nf.A. t7'1k 4-„f/y(CA Lth j.Str J�t1f3bate: ) ( -3 -,9 C Phone#: 508-580-0094 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/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#: ACG oRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 01/20/2021 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 have ADDITIONAL INSURED provisions or 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 Shannon Gallagher Roger Keith&Sons Insurance Agency PHONE (508)583-1106 FAX (508)583-8478 (A/C,No,Exit: (A/C,No): 1575 Main Street E-MAIL sgallagher@rogerkeith.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Brockton MA 02301 INSURER A; Selective Insurance Company of America 12572 INSURED INSURER B: Selective Ins Co of South Carolina 19259 Sign Design Inc INSURER C: Selective Insurance Company of the Southeast 39926 170 Liberty St INSURER 0: INSURER E: Brockton MA 02301 INSURER F: COVERAGES CERTIFICATE NUMBER: 2021-2022 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 SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUULSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD NND POLICY NUMBER IMMIODIYYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X}OCCUR DAMAGETORENrED 500,000 PREMISES(Ea occurrence) S X CONTRACTUAL MED EXP(Any one person) S 15,000 A X NO RESIDENTIAL EXCLUSIONS S 2379251 01/21/2021 01/21/2022 PERSONAL BADV INJURY s 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY I X]JE T LOC PRODUCTS-COMP/OP AGG S 2,00D,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) S B OWNED SCHEDULED A 9107007 01/21/2021 01/21/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 5,000,000 A EXCESS UAB CLAIMS-MADE S 2379251 01/21/2021 01/21/2022 AGGREGATE s 5,000,000 DED RETENTION S S WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 C OFFICER/MEMBER EXCLUDED? N NIA WC 9080309 01/21/2021 01/21/2022 (Mandatory In NH) EL DISEASE-EA EMPLOYEE S 1,000,000 11 yes.describe under 10 ,00000 _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S , CONTRACTORS EQUIPMENT UNSCHEDULED EQUIP 353,000 A LEASED/RENTED EQUIPMENT S 2379251 01/21/2021 01/21/2022 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Policy limits in effect at policy inception. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SIGN DESIGN INC SAMPLE CERTIFICATE ACCORDANCE WITH THE POLICY PROVISIONS. 170 LIBERTY STREET AUTHORIZED REPRESENTATIVE/'��� BROCKTON MA 02301 C!/i-}- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD PERMIT COPY 143858 j Version 03 I Sign Relocation • 10-29-21 • Removal of Existing Post&Panel on WO 143751 • Permitting&Reinstallation of Existing Post&Panel on WO 143858 • Mass DOT (New Concrete Footing with J-Bolt Cages) • • 12"x 12"Steel Plate with Holes for 5/8"Bolts; Webber&Grinnell Welded to ExistingPosts 121 /4n • J Bolts With Nuts/Fastener a 8 N King St f ' •• 36"x 24"x 24"Concrete Footing Northampton,MA • • All Visible Painted Blue to Match Existing Posts - • oribi.„_„, ,,.. 1 • we e I PLATE MOUNT DETAIL w grinneP • X d . _ iliiiirill N S U R A N C E Q 0 -- HOME • AUTO • BUSINESS 1 9„ - 12" 125"(Existing Posts on Center) 10 SIGNDESIGN VISUAL COMMUNICATION SOLUTIONS ,t .a L I 170 Liberty Street ice Brockton,MA 02301 508-580-0094 { ° Ron Ferrigno th s • ....1 • Kelly Young 24" 24" • CW SCALE 10% SHEET 01of02 F;2020 This document and the designs herein were maimed expressly tot this project and Timm the properly cl Sge Design Inc.They may not 0e reproduced or used for any other ptap ose without the"mitten consentputhuriyation of Sign Design.ion The colors parted on this page are strictly ropt0sealati0nal and should not be copied or reproduced in any way and'oo used m connection with this priest.Refer tc color spec sheet kw prpn -__--_--------'-^ --J WOW match an05ystem selection. PERMIT COPY 143858 Version 03 10-29-21 \ ., Mass DOT Webber&Grinnell CLIENT TO REMOVE STONEWORK & ADJUST LANDSCAPING AS NEEDED 8 N King St �1. \ -y Northampton,MA EL 23-HS-4 ---, , >Y TRUST ' •UT 22 S.F. `\ \ \ ._,., . N BEGIN PROP. ' \ , SHLO AIPI:, • s "84 \ALT. NO. 8637 r\ �� (SECTION 1) i , 1 EL 23 1 \� SEE DETAIL 5 a _ °inner: # TRUST '• .� l r- ry • ,,. , 391 S.F. _ _, gems - HOME •• Pus •• BUSINES` V ., . \ • - m I ; [,__. is63.... lb •U E 1 — I / 9•± I°D � —I RUST I / s 3S.F. ' 4 i .` ' 1 EDr— i s I 1: I `' ' ' N PROPOSED - PHOTO SCALE 1:80 APPROX II — PROPOSED SIGN LOCATION TBD �a111 4 ., t '$ / G BEGIN PRC roit . EXISTING SIGN LOCATION SHL �� __ ALT. NO. 86 , _ `li +f.'�� 33 f �_ tom, G22't (SECTION t SOUTH = SIGNDESIGN —` — ... CI 1 962 %F I J' _ , - NONIN►Nt10N CT ----• VISUAL COMMUNICATION SOLUTIONS . ... EAStNtiMPTON • I To �' 170 Liberty Street • A •—L�5r± ' [ Brockton, MA 02301 D PROP. SHLO ALT. webber& 508 580 0094 . 8637 `► 0 gr-VMC11 (SECTION 1) — 48 16 • AUTO U51 t 8 NE55 .. HOME Ron Fer g o ri n BRIDGE ROAD 1940 COUNTY BASELl�NE a .S`' •, % spy►. r' Proposed Highway Layout Line: . , ..��.. Kelly Young TRUST Existing Highway Layout Line: EXISTING - PHOTO SCALE 1:80 APPROX CW SCALE NONE Property Line' SHEET 02 of 02 P 2020 Pus document and the designs herein were produced expressly loe Ors prpjecl and remain the properly of Sign Design. Inc.They may not be reproduced or used for any other purpose without the written cotuenl/autnuntation of Sign Design.Inc The tutors Netted on thus page are strictly representational and should nor be corned or reproduced in an/way an&or used in connect.n with this project Ntle,to color spec sheet for proper number midland reeler,,selection.