11A-047 (2) I VILLONE DR BP-2018-1221
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map—Block: I IA-047 CITY OF NORTHAMPTON
Lot,-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category, INSULATION BUILDING PERMIT
Permit# BP-2018-1221
Project# JS-2018-002181
Est Cost:$2226.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 11979.00 Owner: BROWN KATHY
Zoning: URA(100)/ Applicant: GREEN COLLAR LLC
AT. 1 VILLONE DR
Applicant Address: Phone., Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.511812018 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSU LATION
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 if Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Owl- 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 s epature:
FeeType: Date Paid: Amount:
Building 5/18/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
R E C -- Department use only
ity of Northampton Status of Permit
wilding Department Curb CuUDaveway Permit
MAY 1 8 2018 212 Main Street SiwensephcAvailability
Room 100 WaterNtlen Average y
No hampton, MA 01060 Two Sets of Structural Plans
DEPT OF BURDWOINSP OTIONS
Nomm�MmoN.Me 413- 87-1240 Fax 413-587-1272 Plof(Stie Plans
Other Specify...
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 4— 11
1.1 Property Address'. This section to be completed by office
Map I,(A- Lot ®, Unit
C' Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pont) Currant iling Atldress'
N� e� j 3) SPY.— 328H
elephone
Signature
2.2 Authorized Anent: $SI IVstsh'D'I S�"
Green Collar, LLC -2-MeiTG0`Unil B. South Hadley, MA 01075
Name(Prir>h Current Mailing Address'.
/C 413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
ItemEstimated Cost(Dollars)to be Official Use Only
=Iced b ermit applicant
1. Building Z Z'LG 62 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee y��r
4. Mechanical(Hi 06
5. Fire Protection
6. Total=(1 +2+3+4+5) 'L 71 7 L Z- Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued' / ea
Stgnat zzl
Building missionodlnspector of Buildings / / Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tho column to be BMW in IT,
Building Deynmient
Lot Size
Frontage
Setbacks Front
Side L: R: L:. R:
Rear
Building I[eight
Bldg. Square Footage
Open Space Footage
ant arca minus burg&p-,d
urkin )
#of Parking Spaces
Fill:
(1ndm—&tunmion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW ®X YES O
IF YES, date issued:
IF YES Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW OX YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,r�excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO X0 X
IF YES,than a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows At aralion[s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding[DJ Other[SajX
Brief Desch tion of Pro used
Work INgULATICPN/W EATHERIZATION
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X _No
Plans Attached Roll -Sheet
ea.If New house and or addition to existing housingcomplete the followina:
a. Use of building 'One Family Two Family Other
F. 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?
T Method of heating? Fireplaces or W oodslaves Number of each
g. Energy Conservation Compliance, Masscheck Energy Compliance form attached?
F. Type of construction
i. Is construction within 100 ftof 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, SEE ATTACHED DOCUMENT as Owner of the subject
property
hereby authorize Green Collar,LLC
to act on my behalf, in all matters relative to work authorized by this building permit application.
SEE ATTACHED DOCUMENT
Signature of Owner Date
I //' ��� A .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 pains and penalties of perjury.
F,9.c.Y Cu J k..,✓r.
Print Nam
Signature of C)m.,1Ageot Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holden CS-108817
License Number
Robert Calhoun
8/23/2018
Address Expiration Date
390 Newton SL South Hadley, MA 01075
Signature Telephone
413 532 1817
9.Realetered Home Improvement Contractor; Not Applicable ❑
Company Name Registration Number
Green Collar, LLC 181415
Address Expiration Date
3 Main St. Unit B. South Hadley, MA 01075 Telephone 413 532 1817 3/31/2019
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....... W No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(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 108.3.5.1.
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,it he or two family dwelling,attached or detached structures accessory to such use and/or tarts
structures.A person who constructs more than one home in a two-year Period shall not be considered a homeowner.
Such"homeowner'shall submit to the Building Othcial,on a form acceptable to the Building Official,that he/she shall he
responsible for all such work Performed under the building permit.
As acting Construction Supervise r your presence on Iltc,jnb site will he required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference m Chapter 152(Workcry Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may he liable for persons)
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,Stale//and Local Zoning Laws and State of Massachusetts General Laws Annotated.
I lomeowner Signature /V ..
City of Northampton 212 Main Street. Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: l V-'Vo' cr, L&-.ds, l*- O1o6-3
The debris will be transported by: A/�/r
The debris will be received by:
Building permit number:
Name of Permit Applicant /, ✓�c �a ��a/
-
/G - 2./Y
Date Signature of Permit Applicant
/VW 5 �v l'V"* /Le, Gne--&
Owner Authorization Farm
;�svrnar"5� a�ei
Owner of the property located at:
1 ✓'tom pr.
(Property Address)
f f
(Property Address)
hereby authorize Green Collar a certified Mass Save Home Performance
Contractor, to act on my behalf to obtain a building permit and to perform
work on my property.
(owner's Signature)
(Date)
* Worker's Compensation and Employer's liability Policv
5�Berkshire Hathaway
AmGLIARDInsuranceCompany-A Stock Co.
I ( Y Policy Number R2WC855214
Insurance fleneyval of NEW
jX G U ARD Compare es NCCI No. [2 873]
Policy information Page (AR) /Uri"d�✓v, QK.irr.Ds.i
[I)Named Insured and Mailing Address Agency /
GREEN COLLAR ILC TIERNEY INSURANCE AGENCY, INC.
3 MAIN STREET UNIT 8 16 NORTH ELM ST
SOUTH HADLEY,MA 01075 Westfield, MA 01085
Agency Code: MATIERIO
Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC)
(2) Policy Period
From September 23,2017 to September 23, 2018, 12:01 AM, standard time at the insured's mailing
address.
[3) Coverage
A. Workers'Compensation Insurance - Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
S. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed
m item[370. The limits of our liability under PartTwo are:
Bodily Injury by Accident -each accident $500,000
Bodily Injury by Disease -each employee $500,000
Bodily Injury by Dlsea5c - policy limit $500,000
C. Refer to Residual Market Limited Other States Insurance Endorsement-WC2003068
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
[4) Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 13,325
Total Surcharges/Assessments $ 584.00
Total Estimated Cost 13 909.00
pUtMAL use _OM Gage- 1 Information Page
MGA 'RZWCa5511n WC 000001A
Date : 1019212011
MANOTE
Issuing Office:P.O.Box A-H, 16 S. River Street,Wilkes-Sarre,PA 18703-0020 0 www,guard.cum
The Commonwealth of Massachusetts
Department of Industrial Accidents
�—' Office of Investigations
600 Washington Street
Boston, MA 02111
wwrn.macs.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiv,ltion/Individual): Green Collar, LLC _
Address: 3 Main St. Unit B.
City/State/Zip: South Hadle , MA 01075 Phone#: 413 532 1817
Are you an employer? Check the appropriate box: Type of project(required):
I.® I am a employer with & 4, ❑ I am a general contractor and I
employees (full and/or part-time)." have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in an acil employees and have workers'
y capacity.➢ 9. E] Building addition
[No workers' comp. insurance comp, insurances
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' 13.[K Othednsulation/Weatherization
comp. insurance required.]
*Any applicant that checks box HI n ust also fill out the section below showing their worker.enntpen,atu n policy information.
c flommwners who submit this affidavit indica(,,,,they ereduiug all work and then hircovu,ide ccovaners must submit a new affidavit indicating such.
it untraener,that check this box must attached an additional sheet showing the name of the sub-convaqur,and,nue whether or not those mtities have
employee,. Ifthe,ub-cont nctnrs have employees,they,ned provide than ,eke in cont..policy nuntb,a..
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ AmGUARD Insurance Company -A Stock Co.
Policy#or Self ins. Lic.#: R2WC855214 _ Expiration Datc: 9/23/2018
Job Site Address:I IV)lA, —a- - 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 S Of 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 DEA 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- �'�{'� _. _. _ _. Dalc_S, ��i 04�,/g _
Phone#: 413 532 1817
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#:
"-?assachusetts Department st PaoimIBoard
of Budding Rgulations andSt
License. CS-109817
ROBERT CALHOUN
360 NEWTON ST
SOUTH HADLEY MA 6'1,76
Comm�sswner 0612312018
_` � _ �>le �c�nrrrcazu!��rlf� o�r/f�tt:✓.��cfiu�.;P,l�
3 Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Registration: 781415
3 MAIN ST.UNIT B. Expiration: 03/31/2019
SOUTH HADLEY,MA 01075
Update Address and return and. Mark rasson for mange.
❑ Acidness ❑ Renewal 0 Emaloymint O Lost Card
/L, t...............iiL„-i/......
O1MoIE NAPROVE EACONTaPpuladan
HOMEIYPpOVEMENi CONTpACTOP Registration valid forindividual use or6y
TYPE:LLC Seim.the exPinabon date. a bund ratum to:
[[[CCC aachurab6n E6pi[A04tt office of Consumer Affairs and Busun ss papulation
' _ 181415 03!31/2018 10PMI,Plana-Sadaffin
GpEEN COLLAR LLC, Boston,MA 02116
STEVEN ECK
3 MAIN ST.UNIT B. L
SOUTH HADLEY,MA 01075 Undersecretary Not Velld without signature