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38D-056 (3) The Commonwealth of Massachusetts Department of Industrial Accidents !>! 111 ' Office of Investigations I =Min- r 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business /Organization Name: Apollo Contracting Address: 27A Hemenway Rd, Leverett, MA 01054 City /State /Zip: Phone #: 413 835 1336 Are you an employer? Check the appropriate box: Business Type (required): 1. g 1 am a employer with 1 employees (full and/ 5. ❑ Retail or part- time).* 6. ❑ Restaurant/Bar /Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non- profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required] ** 11.0 Health Care 4. ❑ We are a non - profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. © Other Construction *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. * *If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: American Zurich Insurance Company 1400 American Lane Schaumburg, III, 60196 Insurer's Address: City/State /Zip: Policy # or Self -ins. Lic. # 6ZZUB5B29496 -6 -12 Expiration Date: 3/27/12- 3/27/13 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 insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov /dia 1 N i Q 0 0 1,di �,,, SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of license Holder : Neal Bannon 1047()S License Number 27A Hemenway Rd, Leverett, MA 01054 R/1 R/24 Adc}f s Expiration Date 413 835 1336 Si nature Telephone 9. Registered Home Improvement Contractor; Not Applicable ❑ Neal Bannon 167564 Company Name Registration Number Apollo Contracting 10/4/12 Address Expiration Date 27A Hemenway Rd,Leverette, MA 01054 Telephone 413 835 1336 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes RI No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 1083,5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-vear period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official. that he/she shall be responsible for all such work performed tinder the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing JJ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [D] Other [dJ Brief Description of Proposed install roof mounted solar array on asphalt shingle roof, framing is Work: 2x6s 20" OC w/ a 10' span Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Andrew Donson r t4 of V1/41� , as Owner of the subject property hereby authorize Neal Bannon to act on my behalf, in all ma ers re ative to work authorized by this building permit application. ! d Oc/ /2 Signature of er Date Neal Bannon , as Owner /Authorized Aggat hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Neal Bannon Print N . I LA . .. 1 _ l G / 3 / 1 Z Signature of • - •'ent Date Section 4. ZONING — All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage °lo Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces Fll: (volume & Location) A. Has a Special Permit /Variance /Findi g ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the R istry of Deeds? NO ® DONT KNOW YES IF YES: enter Book Page / and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ( , Da Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, a vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . - vcNaIancuL uac vn City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability i o, u I 2 2 Room 100 VVater/Well Availability Northampton, MA 01060 Two Sets of Structural Plans \________________ VEPT. OF BUILDING NORTHAMPTON NMA� oNS 13 -587 -1240 Fax 413- 587 -1272 Piot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 40 Winthrop St, Northampton MA 01060 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: L0 ; v * --1 R r` i. �Pr o1 Andrew Donson e V.-1, K 401 KA.r^-/ ! � ' 5 g . °C 1 q Name (Print) l Current Mailing Address: • I` /I ' lin 1 ' Telephone _2 Signature 2.2 Authorized Anent: /J Neal Bannon 4 27A Hemenway Rd, Leverett, MA 01054 Na , Prin i7 Current Mailing Address: 413 835 1336 Sig ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $15 (a) Building Permit Fee 2. Electrical $5000 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) $ Check Number 0 7 /.5 W I Da This Section For Official Use Only Permit Number: Date Building Issued: File # BP- 2013 -0474 APPLICANT /CONTACT PERSON APOLLO CONTRACTING ADDRESS/PHONE 180 VILLAGE PARK RD AMHERST (413) 835 -1336 PROPERTY LOCATION 40 WINTHROP ST MAP 38D PARCEL 056 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �,� / Fee Paid /:� Typeof Construction: INSTALL ROOF MOUNTED SOLAR ARRAY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 104705 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOWATION PRESENTED: pproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site 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 - •• e lition Delay // Sig ature o Bui d' g 4 fficial 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. 40 WINTHROP ST BP- 2013 -0474 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D - 056 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: SOLAR PANELS BUILDING PERMIT Permit # BP- 2013 -0474 Project # JS- 2013- 000758 Est. Cost: $20605.00 Fee: $126.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: APOLLO CONTRACTING 104705 Lot Size(sq. ft.): 6403.32 Owner: DONSON ANDREW C & ERIN HOLMAN Zoning: URB(100)/ Applicant: APOLLO CONTRACTING AT: 40 WINTHROP ST Applicant Address: Phone: Insurance: 180 VILLAGE PARK RD (413) 835 -1336 AM H E RSTMA01002 ISSUED ON:10/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ROOF MOUNTED SOLAR ARRAY POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/25/2012 0:00:00 $126.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner