2011-484 Cumberland Farms TOWN OFQ UEENSBURY
4ro742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20110484 Date Issued: Friday, December 16, 2011
This is to certify that work requested to be done as shown by Permit Number P20110484
has been completed.
Tax Map Number: 523400-303-005-0001-024-000-0000
Location: 410 QUAKER Rd
Owner: V.S.H. REALTY INC.
Applicant: VSH REALTY INC.
This structure may be occupied as a:
Sign
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the 'ti /y) ,r/ rs^/
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
.411111A TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20110484 Application Number: A20110484
Tax Map No: 523400-303-005-0001-024-000-0000
Permission is hereby granted to: VSH REALTY INC.
For property located at: 410 QUAKER Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: VSH REALTY INC.
100 CROSSING Blvd#9003 Sign
Total value
FRAMINGHAM, MA 01702-5401
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2011-484
Change of Copy-24 sq ft sign for Cumberland Farms
$0.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, October 04,2012
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the T -ef Queensl,Qry; Tues$„ay,.Pctober 04,2011
.� f
SIGNED BY c„.4=10-,fir' p`v` :, for the Town of Queensbury.
Director of Building&Code Enforcement
'74 OFFICE USE 0,72.. �1 -r30
'�n I r-r /, '<'
TAX MAP NO. / ERMITNOERMITFEEII
s
C 4a SEP :" 2811
p J I
DEPOSIT
APPROVALS:
SIGN PERMIT APPLICATION: t 5'`'''' C,r_ `5`'BulLniNc Eici
A permit must be obtained before installation of your permanent sign. All applicants'spaces on this application must
be completed and must appear on the application form. , `
OWNER: 1.0/38.Eie.119/(/,� /=/912-712,Z.' INSTALLER/BUILDER: My�'z7 SA:7:e Y/C��
fee.? C;�'• .:}S rive !itiJ /Q/). ),,e 7e.2-
ADDRESS: .i--na/-)7/A/6yi9,2J,/yf// 6/170.1L-- ADDRESS: �f3/(/ 5 i.e�G7` /,,S7 4''"i/ 3 y
PHONE NOS. _6tf-- ` e -Avio PHONE NOS. S/
LOCATION OF PROPOSED INSTALLATION:(LEGAL ADDRESS)
BUSINESS COMPLEX/PLAZA/MALL NAMME:: /tf/el
BUSINESS NAME: G L //���'7//Z7
CONTACT PERSON FOR SIGN CODE COMPLIANCE:1W4.1•0/// , /e ONE:
TYPE OF SIGN PROPOSED: Xfreestanding wall awning projecting
IF SIGN IS TO BE ILLUMINATED,PLEASE INDICATE: ,jntemal _External _Incandescent _Neon _Other
DO SIGNS CURRENTLY EXIST ON THE PROPERTY? Yes No
IF IF YES,LIST ALL EXISTING SIGNAGE: P7 ke/V OA/IC/ �/
The application creates a change New X F/ e,,E t2/v'/
in the following existing site Change in number of signs from to
conditions(fill in all applicable Change in setback for sign from to
spaces): Change in size of sign from to
Change in height of sign from to
Change of wording/copy from: McN-1/7 L. Pie/e,6-7 ' to: �J C_`leeL L.ge.'/ p/e/C.-eS
Sign Wording/Copy: CP ! Pie/�i4"S
Sign size: Length lit x Width =Total Sq. ft. . -i 'fir Sign Height(freestanding sign): , 77e
Color and Material to be used: 2341-) lGVN/7 E P/,i9 S%/L
✓ Provide 2 copies of a scaled drawing or surveyed plot plan with the following information: , /g7'//%J
o Location of sign(walls signs: drawing of the facade 16/t/
the sign will be located on,indicate sign on facade) QUESTIONS? CALL 7614256 OR EMAIL
o Height of freestanding sign codesqueensbury.net 6A/L:),
o Depth of projecting sign
o Distances from front and side property lines. VISIT OUR WEBSITE FOR MORE INFORMATION
I Provide 2 drawings or photos of sign design. www.queensburv.net
I Provide Applicant and Owner's signature(permission
for placement of sign on the property or building).
Declaration: To the best of my knowledge,the statements contained in the application,together with the plans and
specifications submitted,are a true and complete statement of all proposed work to be done on the described premises and that
all provisions of the Zoning Ordinance,and all other laws pertaining to the proposed work shall be complied with,whether
specified or noted, and that s work is uthoriz-• by t wne 9/-2/`
APPLICANT SIGNATURE: L �( � �.. DATE: C/`-2/
I hereby authorize the applicant to place a sign on my property or building.
OWNER SIGNATURE: 'S.&5 I)179 ('ftk) diATE:
CI, Town of Queensbury • Community Development Office • 742 Bait Road, Queensbury, NY 12804
• n•
Cumberland Y 'F
FAR AAS
July 15, 2010
To Whom It May Concern:
Cumberland Farms, Inc., with a usual place of business in Framingham,
Massachusetts, does hereby authorize CAROLYN A. PARKER CONSULTING to apply
for and represent Cumberland Farms, Inc. in filing of any applications for required
permits and/or approvals for the LED PRICE PANELS at our store/self-service gas
station including, but not limited to, appearing before any governmental agency at
general meetings or public hearing addressing such construction/improvement of
Cumberland Farms retail facilities.
Cumberland Farms Gulf Group of Companies,
Manny Paiva
Planning Department Manager
COMMONWEALTH OF MASSACHUSETTS
MIDDLESEX COUNTY
Subscribed and sworn to before me this 15th day of July 2010 by Manny Paiva who is
personally known to me.
MAURE DlC�KS�Iu
i +r
e'JOtary Pubde
f w rH Of MASSACHUSETTS f Notary\\c„sc
: A„ „Icycl
My i:u Mission E.puet
aaarcn isS,toes r My Commission Expires:
Cumberland Gulf Group of Companies
100 Crossing Boulevard,Framingham,MA 01702
508-270-1400
•
"'4 CERTIFICATE OF LIABILITY INSURANCE "°°"""''
5/6/2011
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 be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may requke an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
t PRODUCER CONTACT
IOW $artlt3lr
Coakley Pierpan Dolan & Collins Insurance riMENtc.No.Ent1: (413)664-9366 FAX
um No,(413)664-6504
26 Union Street EA m_ahartley@cpdcinsurance.com
musaERCUSTOMERS)#00003271
North Adams MA. 01247 PISURERIS)AFRADWG COVERAGE RAW s
ISD INSURERA_Ohio Casualty Group 24082
T
asumna:Travelers Indemnity Co of CT 25682
M&D Services Inc
ammER c American Fire And Casualty Co. 24066
PO Box 702Muses E
INSURER E
Lanesboro MA. 01237
INSURER F: —
COVERAGES CERTIFICATE NUMBER:11-12 BOP,AUTO,WC,011113 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. NOT AATHSTANDING 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 CLARAS.
LTR TYPE OF INSURANCE POLICY ISOMER (fin (MWD yyPOUCY yyyy) UNITS _
GENERAL LIABIUTY
EACH OCCURRENCE s 1,000,000
X COMMERCIAL GENERALAL^LIABHJTY [lARI/CGE TOMa mamma)
RENTED
CLAats.MADE (X OCCUR BK052995646 5/19/2011 5/19/2012 I S ) $ 105,000
MEOEXP(Myalepe�san) s 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE $ 2,000,000
-
GRIL AGGREGATE UMrr APPUES PER PRODUCTS-COMP/OP MGG S 2,000,000
X i POLICY[ 1-11Loc $
AUTOMOBILE UABNJTY COMBINED SINGLE UNIT
I (Eeaaidet) S 1,000,000
I ANY AUTO
B ALL OWNED AUTOS
8A1934C512 1/1/2011 1/1/2012 BODILY INJURY(Per person) S
X BCOILY IN.NRY(Per accident) S
SCHEDULED AUTOS
PROPERTY DAMAGE
X HIRED AUTOS (Per S
X NON-OARED AUTOS "Sol Payments $ 5,000
Uninsured metered 8I spi t Sea S 100,000
X UMBRELLA LIAR OCCUR
-- EACH OCCURRENCE $ 1,000,000
EXCESS UaS CLAIMS-MADE AGGREGATE S 1,000,000
DEDUCTIBLE s
A X RETENTION S 10,000 OS052995646 5/19/2011 5/19/2012 S
YYDRKERS COMPENSATION II yy�STp7%
C AIND��N Y!N X 1Ta2YUMITS
OFFICER/PASSER D(CLllDED? N!A E.L.EACH ACCIDENT $ 500.000
IMyandel ry in NH) 1WA52995646 /19/2011 5/19/2012 E.L DISEASE-EA EMPLOYEE s 500,000
aDESC'18Po OPERATIONS below E.L OISS'SE-POLICY HIRT S 500,000
DESCRIPTION OF OPERATIONS!LOCATIONS I VBUCLF-S(Attach ACORD 101.AddMaral RemadoeSclledlae,A more space is required)
The certificateholder is listed as an additional insured with respects to General Liability when required by written
contract or agreement, waiver of subrogation included
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.
AUTHOR REPRESENTATIVE
Audrey Hartley/ADDEAR (:)."‘‘S"`-'211-4-41-'elli
ACORD 25(2009109) ,a 1988-2009 ACORD CORPORATION.All rights reserved.-
INS025proioe The ACORD name and logo are registered marks of ACORD
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PROPOSAL DRAWING SPECIFICATIONS a
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DRAWING NUMBER:CUMB2203-040711-01 REV. A ,s /a
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CATALOG NUMBER: PCS-32SPDFITG a o
T-12-800 H.O.-F42T12/CW/HO,qty 6 $ �
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Input Voltage:120 VAC w SIGNS
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TOTAL=3 Amps *SIGN TOLERANCES:+1/8 -1/2" CONFORMS To ULSTD48 / ;Z i d 8 J
Skyline Products Electronic Price Displays
Installation Guide
Prepare the Sign for Operation
Price Modules
Verify that the film in each module is still positioned in the film guides. Ensure that film hasn't
been bumped or pushed out of the track during shipping and installation. For proper operation,
the film must be in the film guide tracks located at the top and bottom of each module. Price
modules are easily removed from the sign frame by pushing up and then pulling outward.
Upper Film Guide
Price Module
(inside view)
1
l
Lower Film Guide
a ;s
3,a
Shipping Blocks
Signs built with 66" and 91" digits are assembled with a shipping
block(s) located at the bottom of the module chassis. Shipping blocks
help prevent module movement or damage to the film and roller -,a= nrz� -' ,
assemblies while in transit.
Shipping Block
Ensure to remove all shipping blocks in 66"or 91"modules. Shipping blocks on the modules are
tagged with warning labels. Additional warnings are also prominently posted on the exterior of
the sign cabinet.
Important: SHIPPING BLOCKS MUST BE REMOVED BEFORE OPERATING
THE SIGN.Serious damage can occur to the modules if blocks are not removed before
operation, and the sign warranty will be voided.
This document and the drawings costumed herein contain oreprfrtary mforrratot exclusue to Skyline Products,Inc.,and shad not be used,reOrcduced,copied,
disclosed.or exhibited in whole or in part for manufacture,procureme st.or for arty:Lhe-purpose except as soeciticaliy authorized by Skyline Prcdutt Inc.
Copydg:it 2009 Skyline Products,Inc
Page 6
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