24D-075 (2) �„ The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
`, -- °• 1 Office of Investigations
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1 Congress Street, Suite 100
Boston, MA 02114 -2017
-,` www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
NorthEast Solar Design Assoc.
Address: Elm St.
City /State /Zip:Hatfield, Ma. 01038 Phone #:413 - 247 -6045
Are you an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 8 4. [] I am a general contractor and I
employees (full and /or part - time).*
have hired the sub contractors 6. El 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. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑Building addition
required.] 5. ❑ 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.[] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no Solar Install
employees. [No workers'
13. 0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r 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 any employees. Below is the policy and job site
information.
Insurance Company Name: Hanover Insurance
Policy # or Self -ins. Lic. # :WHN5715134 - 02 Expiration Date:
Job Site Address: a () / H � �J7 - hill( (. /7) City /State /Zip: AV Q / / r ( , J 7124 .
Attach a copy of the workers' competfsation policy declaration page (showing the policy number and expiration date). d /did
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 cer ' , 4 the riFs and enalties of er"ury that the information provided above is true and correct.
.
Si natl. ■., , _ _ .' —� .t. C – jam' Date /. . / 2 -- __
i
Phone #:413- 247 -6045
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 #:
MR'Y- 01-2812 15:38 From:123 Paee:1'1
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, PC/CC / n , as Owner of the subject property
NorthEast Solar, Phillip Baunsgard
hereby authorize to
act on my behalf, in all matters rela.iv- to work authorized by this building permit application.
.W1 //. -_,id" .�... 31-
Signature of wne Cate
h ►'t rG n� Iv C1 ( as owner /Authorized
Agent 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 D- and penalties of perjury.
1 rn 1 rU!fr
Print Name r b
rr GG k I / l
Si azure of OwnertA.rt Cate
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ; Phillip Buansgard CS- 106113
License Number
11Edward Ave. outhampton, Ma. 01073 06/07/2015
•
Adz! ess Expiration Date
I , / � .� . 2./ A (413) 247 -6045
Sig l . re Telephone
SECTION 13 - 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 0 No 0
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
8.1 Registered Architect;
Not Applicable El ....
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional En:Ineer a
;Take Smith Thayer St. Assoc, Structural
Name Area or Responsibility
.1 Thayer St. So. Deerfield, Ma 01373 ! i 74/- F.0 ......
Address Registration Number
4 (413)665-4O1 8 ,6/3 a/j
,.nat _ Telephone Expiration Date —
'Chris Vreeland PrecisionD., sio......... -.
Precision Decisions LLC E !Electrical.
Name Area of Responsibility
PO Boy. 179 West Stockbridge,Ma 01266
I k
Address Registration Number
(413) 269-4965 .9 D,(/
Signature Telephone Expiration Date
1
Name Area of Responsibility
Address Registration Number
Signature Telephone ixpiration Date
Name Area of Responsibility
Address Registration Number
Si nature Telephone Expiration Date
9.3 General Contractor
Applicable pp Icabte 0I
_. .. I
Company Name:
Responsible . ...... .................. „ „ . ....,,.. ..
In Charge of Construction
Address
Signature - Telephone . -
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 0
Brief Description Enter a brief description here. Install 151 solar PV panels on roof of auto body shop
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
❑ A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1"
1
2 nd
2
3
3
4
4
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
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
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES (0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.
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• Versionl .7 Commercial Building Permit May 15, 2000
Department use only
O — i 2012 City of Northampton Status of Permit:
I. Building Department Curb Cut/Driveway Permit
` Fr 212 Main Street Sewer /Septic Availability
t oS;ECrioNs
AMF7 Room 100 Water/Well Availability
NOR UILD ∎N:: . n s A 07060
+ Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
220 King St. Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Don Muccino 220 King St. Northampton, Ma. 01060
Name (Print) Current Mailing Address:
� ��J��',,/ (413) 584 -3710
(� � �� +ti ,
Signature CI_Q ) 9'- Telephone
2.2 Authorized Agent:
NorthEast'Solar Design Assoc. 136 Elm St. Hatfield, Ma. 01038
Name (Print) Current Mailing Address:
(413) 247 -6045
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (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) /8 , 6'0/ C;•9' O� Check Number � 0 / ✓7
/)/
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date _
File # BP- 2012 -0967
APPLICANT /CONTACT PERSON NORTHEAST SOLAR DESIGN ASSOCIATES LLC
ADDRESS/PHONE 136 ELM ST HATFIELD (413) 247 -6045 0
PROPERTY LOCATION 220 KING ST
MAP 24D PARCEL 075 001 ZONE HB(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 ✓' �� ( 1J1'5y
Typeof Construction: INSTALL ROOF SOLAR PANELS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 106113 -441--1/eAfreOr
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
� • on D- ay
/
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.
220 KING ST BP- 2012 -0967
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 075 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- 2012 -0967
Project # JS- 2012 - 001684
Est. Cost: $189601.00
Fee: $1134.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NORTHEAST SOLAR DESIGN ASSOCIATES LLC 106113
Lot Size(sq. ft.): 8755.56 Owner: MUCCINO DONALD J JR & LISA MUCCINO
Zoning: HB(100)/ Applicant: NORTHEAST SOLAR DESIGN ASSOCIATES LLC
AT: 220 KING ST
Applicant Address: Phone: Insurance:
136 ELM ST (413) 247 -6045 () Workers Compensation
HATFIELDMA01038 ISSUED ON:5/22/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL ROOF SOLAR PANELS
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 5/22/2012 0:00:00 $1134.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner