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32-003 (3) BP-2021-1973 140FAIR STEXT COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32-003-001 CITY OF NORTHAMPTON Permit: Solar Build PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1973 PERMISSIONISHEREBYGRANTED TO: Project# 2021 SOLAR Contractor: License: Est. Cost: 99000 VISION SOLAR 069649 Const.Class: Exp.Date:05/11/2023 Use Group: Owner: DIMOS JAMES &JOHANNA COLLINS Lot Size (sq.ft.) Zoning: SC Applicant: VISION SOLAR Applicant Address Phone: Insurance: 501 BLACK HORSE PIKE (856)335-2249 WC202100017772 BLACKWOOD, NJ 08012 ISSUED ON:09/30/2021 TO PERFORM THE FOLLOWING WORK: INSTALL 71 PANEL 25.205 KW ROOF MOUNTED SOLAR SYSTEM 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. Signature: w I . 1 • IP fi Fees Paid: $75.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner an C /� The Commonwealth of Massachusetts .,, : + . of Building Regulations and Standards FOR -� ���� ;RFjd 2� ��.assac� MUNICIPALITY q .usetts State Building Code, 780 CMR USE oFAl. Bu ildi er App ication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 N°R AM��N� One-or Two-Family Dwelling •o r��cp f This Section For Official Use Only Building Perm i ''S G 1 4/ 97 3 Date Applied: q-3D ZoZI Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 140 Fair St Ext 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: James Dimos Northampton,MA 01060 Name(Print) City,State,ZIP 140 Fair St Ext 856 242 1295 mapermits@visionsolar.com No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other in Specify: Solar Brief Description of Proposed Work2: Installation of 71 roof mount solar panels-25.205 KWDC Photovoltaic system SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 49000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee 50000 ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fe : $, Check No 6 Suppression) `� 1-1 eck Amount: 6 Cash Amount: 6.Total Project Cost: $ 99000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 069649 5/11/2023 Paul Degray License Number Expiration Date Name of CSL Holder 7 List CSL Type(see below) U 501 Black Horse Pike ,r. No.and Street Type Description Blackwood,NJ 08012 U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town, NJ,ZIP R Restricted 1&2 Family Dwelling M Masonry. , RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413 246 9867 mapermits@visionsolar.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 197940 2/9/2022 Vision Solar LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 501 Black Horse Pike mapermits@visionsolar.com No.and Street Email address Blackwood,NJ 08012 856 335 2249 City/Town, State,ZIP Telephone SECTION 6: 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 [X No . 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Paul Degray to act on my behalf,in all matters relative to work authorized by this building permit application. Z7shte.d., 9/2/2021 Print er's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information / ) contained i this application is true and accurate to the best of my knowledge and understanding. ^' Q 2 9/2/2021 Print Owner's or Authorize A?- ";fie(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton A�� , �� Massachusetts i,( el r 44 4 DEPARTMENT OF BUILDING INSPECTION 1! I -3--, '')/ S - 212 Main Street • Municipal Building -^-"K Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 140 Fair St Ext The debris will be transported by: Name of Hauler: Self Haul Away Signature of Applicant: /� --` b2„5,7 Date: 9/2/2021 The Commonwealth of Massachusetts Department of Industrial Accidents --` Office of Investigations Lafayette City Center 4 2 Avenue de Lafayette, Boston,MA 02111-1750 .. www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel=.ibly Name (Business/Organization/individual): Vision Solar, LLC / Paul Degray Address:205 Arch St City/State/Zip: Philadelphia, PA 19106 Phone#: 856 335 2249 Are you an employer? Check the appropriate box: Type of project(required): l.C I am a employer with 50 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling ?.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.* 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 11.0 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 q ] employees. [No workers' 13•❑■ Other Solar 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 joh site information. Insurance Company Name: RSC Insurance Brokerage, Inc Policy#or Self-ins. Lic. #:WC202100017772 Expiration Date:8/24/2022 Job Site Address: ALL LOCATIONS WITHIN NORTHAMPTON City/State/Zip: 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 un the p ins d penalties of perjury that the information provided above is true and correct. Signature: - Date: 9/2/2021 Phone#: 856 335 2249 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(check one): 11:1Board of Health 20 Building Department 3UCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter haye been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s). address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation,and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised -2019 Fax (617) 727-7749 www.mass.gov/dia nmonweaRh ot Massachusetts D: VIS1011 of Professional Licensure Board of Building Regulations and Standards r4j C (,)1) tit rv , sr 1.40, CS069649 p1res: 05/ 11/2023 PAUL tit DEG PO BX 847 SOUTHWICK * • )ftc. C OM M SSiO - r JJ& LI 044ift-sAnct z. . of * ,p ;4654 t4".4C4IL Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 197940 VISION SOLAR LLC Expiration: 02/09/2022 511 ROUTE 168 BLACKWOOD, NJ 08012 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 197940 02/09/2022 1000 Washington Street -Suite 710 VISION SOLAR LLC Boston, MA 02118 JONATHAN SEIBERT 205 ARCH ST 2ND FLOOR PHILADELPHIA, PA 19106 Undersecretary Not valid without signature Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 197940 VISION SOLAR LLC Expiration: 02/09/2022 511 ROUTE 168 BLACKWOOD, NJ 08012 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 197940 02/09/2022 1000 Washington Street -Suite 710 VISION SOLAR LLC Boston,MA 02118 PAUL DEGRAY 205 ARCH ST 2ND FLOOR � ca.(aClrrsti• PHILADELPHIA, PA 19106 Undersecretary Not valid without signature AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) ‘......--%" 08/26/2021 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 April Ruiz NAME: RSC Insurance Brokerage,Inc. PHONE FAX (A/C,No,Ext): (A/C,No): 1350 Avenue of the Americas E-MAIL aruiz@krautergroup.com ADDRESS: 18th Flor INSURER(S)AFFORDING COVERAGE NAIC# New York NY 10019 INSURER A: Gotham Insurance Company 25569 INSURED INSURER B: Republic Franklin 12475 Vision Solar INSURER c: Evanston Insurance Company 35378 511 Route 168 INSURER D: New York Marine&General Insurance Co 16608 INSURER E: Turnersville NJ 08012 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2182429780 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. INSR ADDL-SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREM SESO a occurrence) $ 500,000 MED EXP(Any one person) $ 5,000 A PK202100013583 08/24/2021 08/24/2022 PERSONAL aADv INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B - OWNED / SCHEDULED 5346656 08/24/2021 08/24/2022 BODILY INJURY(Per accident) $ AUTOS ONLY / AUTOS X -.se/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /•• AUTOS ONLY (Per accident) X Comp$1,000 X Coll$1,000 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C X- EXCESS LIAB CLAIMS-MADE MKLV2EFX100752 08/24/2021 08/24/2022 AGGREGATE $ 1,000,000 DED X RETENTION $ 0 $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N D ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A WC202100017772 08/24/2021 08/24/2022 -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Installation Floater A PK202100013583 08/24/2021 08/24/2022 Catastrophe $1,000,000 Occurrence $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This certificate is issued as evidence of insurance coverage only. CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN INFORMATION PURPOSES ONLY ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 00255584 LOC#: A ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED RSC Insurance Brokerage,Inc. Vision Solar POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes NJ Auto Policy:(Applicable to all NJ Vehicles) Carrier-Republic-Franklin Insurance Company Effective:8/24/21 -8/24/22 Policy#5346656 (DETAILS LISTED ON PAGE 1 OF CERTIFICATE) MA Auto Policy:(Applicable to all MA Vehicles) Carrier-Utica National Insurance Company of Texas Effective:8/24/21 -8/24/22 Policy#5386186 Liability-Scheduled Autos&Hired Autos Only;$1 M CSL Comp/Collision deductible-$1,000 AZ Auto Policy:(Applicable to all AZ Vehicles) Carrier-Utica Mutual Insurance Company Effective:8/24/21 -8/24/22 Policy#5395355 Liability-Scheduled Autos&Hired&Nonowned Autos; $1 M CSL Comp/Collision deductible-$1,000 FL Auto Policy:(Applicable to all FL Vehicles) Carrier-AmGUARD Insurance Company Effective:8/24/21 -8/24/22 Policy#VIAU206979 Liability-Scheduled Autos&Hired/Nonowned Autos Only;$1 M CSL Comp/Collision deductible-$1,000 CT Auto Policy:(Applicable to all CT Vehicles) Carrier-Utica National Assurance Company Effective:8/24/21 -8/24/22 Policy#5465174 Liability-Scheduled Autos&Hired/Nonowned Autos Only;$1 M CSL Comp/Collision deductible-$1,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD