11A-038 91FRONTST BP-2019-0916
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IA-038 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0916
Proiect# JS-2019-001533
Est.Cost:
Fee: 565.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sp.R.): 37853.64 Owner: LADNER JESSE
Zoning:URA(100)/ Applicant: GREEN COLLAR LLC
AT. 91 FRONT ST
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:2/22/2019 0:00:00
TOPERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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 Sienature:
FeeType: Date Paid: Amount:
Building 2/22/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
=,v'j-v CArl vim/
Department use only
EIVED City of Northampton Status of Permit:
REC Building Department Curb CWDrlveway Permit
212 Main Street Sewer/Septic Availability
FE0 7 2 2019 Room 100 Watedi Availability
orthampton, MA 01060 Two Sets of Structural Plans
h e 41 -587-1240 Fax 413-587-1272 Ploi Plans
DF IT nP run Dm¢.mISPFCT'0.s Omer Sped
PLICATION 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
GI Fit)+ S4 Map 1`1 Lot OJ'�' Unit
gene Overlay District
IVGr+ha"
Elm St.District CB OieWct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDRGENT
2.1 Owner of Record:
es3C Ladner ii S4- Nc)r4niet¢on MY
Name(Print) Current Mallin Address'
SEE ATTACHED DOCUMENT Telephonee�, - qac 3734
Signature
2.2 Authorized Apert:
Greed Collar,LLC 351 Newton St. Unit B.South Hadley,MA 01075
Nam nt) Current Mailing Address:
l/T 413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building r (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) ,r Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: Z-Z Z-ZQ1Q
iCommisslunanInspeoax of Buimings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposcd Required by Zoning
This column to be filled in by
Building Deportment
Lot Size
Frontage
Setbacks Front
Side U R: L: R:
Reaz
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&pavol
parking)
#oflearking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW OX YES O
IF YES, date issued:
IF YER Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YER enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW g)X YES O
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(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO OX
IF YES,then a Northampton Storm Water Management Pennit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK icheck all olicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0I Decks [p Siding[0] Other(®]X
Brief Descri lion of Proposed
work: INgULATION/W EATHERIZATION
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes ___2L_No
Plans Attached Roll -Sheet
its.If New house and or addition to existing housing, complete the 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?
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 fl.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 Date
I, ob7 C-A V 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.
Sig der the pains and penalties of perjury.
U
Print Nam l —
Signature of OwnerlAgent Date
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supernsor: Not Applicable ❑
Name of License held., CS-108817
Robert Calhoun License Number
8/23/2020
Atldress Expiration Date
390 Newton St. South Hadley, MA 01075
Signature Telephone
413 532 1817
S Retalshimad Nom Iminnausurnent C t aoto - Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
351 Newton St.Unit B. South Hadley,MA 01075 Telephone 413 532 1817 3/31/2019
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit vnll 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 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 51
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,allached or detached structures accessory to such use and/or farm
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 Official,on a fern 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 ofEmployem to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be 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,State and Local Zoning Laws and State of Massachusetts General Laws 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: q -FVbnI- S+ o
The debris will be transported by: �t f A t_b((, ( a+-
The debris will be received by:t leCA&U�iC ,fie hric� S
Building permit number:
Name of Permit Applicant h ( a
V
Date Signature of Permit Applicant
DoouSign Envelope ID:BDE5468F-DD1C-443A-MAG-61873F 1 BDC24
Permit Authorization
mass save Form
Site ID: 3584254 Customer: JESSE LADNER
]esse Ladner
I, ,owner of the property located at:
(D e,Name,pHmd)
91 Front St Northampton, MA 01053
IPnopeny ween Addpe ) (C"
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
pW
zuagln�e �
blr
Owner's Signature: F,�t,Ssu "�-
Date 11/21/2018 1 9:57 AM EST
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
l , 11Gr 2 - 14 -jq
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 Fe,ice Use Only
Rev.102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u,p 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letlibly
Name (Business/organi�tion/Individuap: Green Collar, LLC
Address: 351 Newton St. Unit B
City/State/Zip: South Hadley MA 01075 Phone#: 413 532 1817
Are you an employer?Check the appropriate box: Type of project(required):
I.® I am a employer with 12 4. ❑ I am a general contractor and 1
employees(Poll and/or part-time).
+ have hired the sub-contractors 6. ❑ 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.[ 9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.E3 1 am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.[M Otherinsulation/Weatherization
comp. insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Conuactors that check this box must attached an additional sheet showing the name of the sub-coutmcmrs and state whether or not those emims 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 job site
information.
Insurance Company Name:_ AmGUARD Insurance Company - A Stock Co.
Policy#or Self-ins. Lic.#: R2WC855214 9/23/2019
rr Expiration Date: �n
Job Site Address: � I 1'1'h%') S? City/State/Zip: oft yy jIOh 1 I IA El 1 66
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 cervi under/the gins and penalties of perjury that the information provided above is true and correca
Signature: 640 Date'
Phone#: 413 532 1817
Oficial use only. Do not write in this area, to be completed by city or town off ciaL
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#:
Works ' Cemsenaatlon and EmOlover'a Llahillty Pelid
erkshire HathawayAmGUARD Insurance Company-Astock Co.
Policy Number R2WC988S71
35214
ilGIUARDCompanles RenewalCCI No.[21873]
r
Polley Information Page(AR)
[3]Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY,INC.
351=n St Unit S 16 NORTH ELM ST
South Hadley,MA 01075.2351 Westfield, MA 01085
Agency Code: MATIERIO
Federal Employer's ID 47-1041086 Insured Is Limited Liability Co. (LLC)
[2] Policy Period
From September 23, 2018 to September 23, 2019, 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
9. Employer's Liability Insurence- Part Two of this policy applies to work In each of the states listed
In Item[3)A. The limits of our Ilablllty 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 Forms
[4] Premium
The Premium Basis and,therefore,the premium will be determined by our Manual of Rules,
Classifications, Rates,and Rating Plans. NI required Information Is subject to verification and change by
audit (Continued on another page)
Total End Policy Premium 10,852
TOW Surcharyu/As usaments $ 389.00
Total Eeelmrtsd tmat 11,241.00
a�feu us! for page-1. Information Page
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