31A-226 (4) 42 HARRISON AVE BP-2019-0254
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block: 31A-226 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0254
Proiect# JS-2019-000409
Est.Cost: $3888.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq. ft.): 9801.00 Owner: WILSON ROBERT H&LINDA E SOPP CO-TRUSTEES
Zorn=URB(10o)/ Applicant: GREEN COLLAR LLC
AT: 42 HARRISON AVE
Applicant Address. Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.8/29/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.ADD R-19 &2" RIGID BOARD TO 356 FREEWALL
SLOPE
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 Occuoancv Signature: FeeTvoe:
Date Paid: Amount:
Building 8/29/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File 4 BP-2019-0254
APPLICANT/CONTACT PERSON GREEN COLLAR LLC
ADDRESS/PHONE 3 MAIN ST UNIT B SOUTH HADLEY (413) 532-1817
PROPERTY LOCATION 42 HARRISON AVE
MAP 31A PARCEL 226 001 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
TyacofConstruction ADD R-19&2" RIGID BOARD TO 356 FREE WALL SLOPE
New Construction
Non Structural interior renovations
Addition to Existing
Accessary Structure
Building Plans Included'
Owner/Statement or License 108817
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
INT
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
Demolition Delay
/t,�,Lj 917711,9
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 W 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.
RE-Q- EIVEU -ity of Northampton Department use only
Status of Penna:
Wilding Department Curb Cul/Diveway Permlt
AUG 2 1 2018 212 Main Street SawarriSapbe Avallebility
Room 100 WatenWell Availability
N rthampton, MA01060 Two Sets Of Structural Plans
DEPT OF WILDING INSP� s41 587-1240 Fax 413-587-1272 PWStta Plans
NOHAIAMPTON.MA
Other Specify
APPLICATION TO CONSTRUCT,ALTER REPA`RR
IIR�ENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINGy
SECTION 1 -SITE INFORMATION ✓` `Ct—ZC
1.1 Property Address: This section to be completed by office
qII e Map 3t 14- Lot ';La�P Unit
l� Son 11� Zone Overlay DisMct
Elm St District CS Dishiet
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4&4 tak( Son
Name(Print) Cunent Mailing Atltlres
via-�57- 75'8i
rgcf Telephone
Signature
2.2 Authorized Anent:
Green Collar,LLC 3 Main St. Unit B.South Hadley, MA 01075
Name(Print) Current Mailing Address:
413 532 1817
Sign Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �g� (a)Building Permit Fee
2. Electrical O O (b)Estimated Total Cost of
Constmclion from 6
3. Plumbing Building Permit Fee /q
4. Mechanical(HVAC) t,L�S
5.Fire Protection ��ff
6. Total=(1 +2+3+4+5) Check Number to
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionerllnspector of Buildings 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 Dcpeement
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage ao
Open Space Footage
tl.ot area minus bldg&paved
parking)
#ofParking Spaces
Fill:
volume&Lavation
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW OX YES O
IF VES, 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 R)X YES O
1F 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(clearing,grading,/�excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO (K X
IF YES,then a Northampton Stoml Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement WindowsAlteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs 1171 Decks i0 Siding(Ol Other I®1X
Brief Descrieelion of Proyyosed / ` we(iSp C
Work: I eLn Xf IUN/WEATHERIZATION l9 31 e" RSi� ,rz/ 4 356 st �o
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Rall -Sheet
St.H New house and or addition to existing housing complete tha following
a. Use of building :One Fari 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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
1. 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, 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 ` ` Data
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
sof—perjury.
�jyLeAX./1 pG
Print Name /
Signatu OwnadAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun
8/23/2018
Address Expiration Date
390 Newton St.South Hadley,MA 01075
Signature Telephone
413 532 1817
9.Ri alatered Name Imorowment 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 Exemodon
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 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,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
stmctures.A person whoconstructs more than home in a two-year period shall not be considered a hameowner.
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 under 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,you maybe Nable for person(.)
you hire to perform work for you under this pemdt.
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 Lows Annotated.
Homeowner Signature
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: 7 L
The debris will be transported by: ✓V N4
The debris will be received by: 4461 l/d ,O-g51r, 'S
Building permit number:
Name of Permit Applicants
Date Signature of Permit Applicant
Columbia Gas
Of MaSSaChl1SCM 60 Shawmut Road, Unit 2 Canton, MA 02021
A ffl w Cerny
OWNER AUTHORIZATION FORM
1, Robert Wilson
(Owners Name)
owner of the property located at:
42 Harrison Avenue
(Street)
Northampton, MA 01060
(Town, State, Zip)
hereby authorize 4�5;"'_ (!�;t'(.
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
Curt�r Sig
atb 4nmtz
`-1- '7L - lY
-Sign Date
4126/2018
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offtee of Invesdganons
wi 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Green Coflar, LLC
Address: 3 Main St. Unit B.
City/State/Zip: South Hadley, MA 01075 Phone #: 413 532 1817
Are you an employer? Check t�propriate box: Type of project(required):
1.2 1 am a employer with 4. ❑ I am a general contractor and I 6. E] New construction
employees(full and/or part-time)." have hired the sub-contractors2.❑ 1 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' y ❑ Building addition
[No workers' comp. insurance comp. insurance.=
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] f c. 152, §1(4),and we have no
employees. [No workers' 13.0 Othednsulation/Weatherization
comp. insurance required.]
*Any applicant that checks box#1 must also fill not 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 most 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 most provide their workers'comp.policy number.
I 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. LLiicc.#: R2WC85521//4�� Expiration Date: 9/23/�20118
Job Site Address: /� �iT� /•PLG City/Stste/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 under thepains and penaf ties of perjury that the information provided above is trues and correct.
Signs re: Date -C /6�r/d
Phone#: 3 532 1817
Official use onitc 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#:
Worker'a Compensation and Emelover's LIabI1Nv POlid
shire Hathaway AmGUARD Insurance Company-A Stock Co.
Al`
Insurance
Policy NumberrR�d of NEW
G UARD Companles NCCI No. [21873] (/q
Policy Information Page(AR)
[1]Named Insured and Mailing Address Agency //VV
GREEN COIIAR LLC TIERNEY INSURANCE AGENCY, INC.
3 MAIN STREET UNIT B 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
M September 23,2017 to September 23,2018,12:03 AM,standard time at me Insured's malting
add ass.
[3] Coverage
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed
in Item[3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident-each accident $500,000
Bodily Injury by Disease-each employee $500,000
Bodily Injury by Disease-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 Fortes
[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/Assesaments $ 584.00
Total Estimated Cost 13 909.00
iffE LOSE _OH Page-t - Information Page
MW :UVAC255214 WC 000003A
m1. :10/02/2017
MMIOTE
Issuing Omcat P.O.Box A-H, 16 S.River Stmt,Wilkes-Bane,PA 18703-0020.w r,.guard.4wn
%laseachusetts Department of Pam¢Beret: -
Board of Building Regulations and Standards,
License.CS-108817 T`...
ROBERT CALHOUN
3H NEWTON ST
SOUTH HADLEY MA 0:076
r - l•"� CAS Ex,',
Comm.ssioner 68882018
dee c!%aln�ytortusealtfi a�C��:sactiur.��l
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Typa LLC
GREEN COLLAR LLC. Registration: 181415
8 MAIN ST.UNIT S. Expira0on: 03/31/2019
SOUTH HADLEY,MA 01075
Update Address and return Card. Mrs resew,As charge
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