29-395 (8) 116 SANDY HILL RD BP-2019-0917
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-395 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 ft BP-2019-0917
Project# JS-2019-001534
Est.Cost: $3321.00
Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sp.ft.): 12196.80 Owner: NOLASCO CLAUDIO
Zonine: Applicant: GREEN COLLAR LLC
AT: 116 SANDY HILL RD
AnalicantAddress: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:2/22/2019 0:00:00
TO PERFORM THE FOLLOWING WORK INSULATIONNVEATHERIZATION
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:
FeeTvne: Date Paid: Amount:
Building 222/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
ity of Northampton Status of Permit:
FIL-
2019 uilding DepartmentCurb Cut/Drivewey Permit
212 Main Street Sewer/Septic Availabil'nyRoom 100 Weter/WeBAvallabil,usvF-TiousN hampton, MA 01060 Teo Sets of Structural Piansm v phone- 587-1240 Fax 413-587-1272 Pbt/Site Plans
Other SpecHy
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAr,MMILY DWELLING
SECTION I -SITE INFORMATION 61) ' ` ��Yr�
11 Property Address: This section to be completed by office
/ IY//_ (Jt0. - WII KrU Map C4 Lot Unit
Zone Overlay District
FIDvcTccrnCL OIOD2
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1 WIdlo NOI2CCo ll \p Sa�4 " Hill Rd
Name( riot) Current Mailin Address.
it7 . 4too - �\5N
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authoriud Agent:
Green Collar, LLC 351 Newton St.Unit B.South Hadley, MA 01075
Nor Cunent Mailing Address.
413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by ermit 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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issuetl:
Signature: -9Z/ 2-ZZ-201 .
Building Commissioner/Inspector 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 filld 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)
N of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW QX YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF Y6 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 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(Gearing,goading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO g X
IF YES,then 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 Alteration(s) ❑ Roofing ❑
0r Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[01 Other[MOX
Brief Descripption of Praosed
Work: IN SULATI UN/W EATHERIZATION
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes _ANO
Plans Attached Roll -Sheet
Ga.M New house and or addition to existing housing complete the follow]na.
a. Use of building :One Family 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 healing? Fireplaces or Woodsloves 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
I. 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 /�,y7 /J Date
I, h �i ( lh o t rt 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.
Si under the ams and penalties of perjury.
Print Name
Signa re of Owner/Agi Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun
8/23/2020
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signature Telephone
413 532 1817
9.Reaistered Home Improvement Contractor: 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.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 Dwellinee 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 soverviser.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
structures.A person who constructs more than one home a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Oficial,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 ofthe 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 may be liable for person(s)
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
Permit Authorization
i uss saw Form
W.eOee.M..or.A,owa.
Site ID: 3621081 Customer: CLAUDIO NOLASCO
11 ej ,owner of the property lasted at:
(Owneh Nemo,pdaled)
116 SANDY-HILL RD FLORENCE. MA 01062
(Napery Anel AOd.w.1 Wayl
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. Im�7
Owttds Slptaeun:
FOR OFFICE USE ONLY
We have assiprd the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
�dh 2-I1 -j q
Participating Contractor Date
Name: CLEAResult
Phone: 800-480.7472
Email:
Pape I a I imr anu Ufa Onry
Raw.Mims
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:
The debris will be transportedby:Gy-le'Cri ca 1 w�
The debris will be received by:(- JJ2 b) i c cf i r e S
Building permit number: /n II/I
Name of Permit Applicant o b l'1 Vl0 U h
2 -� q- O
d
Date Signature of Permit Applicant
The Commonwealth ofMassachuselts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naive (Business/Organizatiowindividual): 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):
1.® 1 am a employer with 17- 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E3 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 8, ❑ Demolition
working for mein any capacity. employees and have workers' 9. ❑ 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 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 [:1 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.® Othednsulation/Weatherization
comp, insurance required.]
Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire onside contractors must submit a new affidavit indicating such.
tConuactors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sabaonvactors have employees,they must provide their workers'com,policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:_ AnIGUARD Insurance Company- A Stock Co.
Policy#or Self-ins. Lie.#: R2WC855214 Expiration Date: 9/23/2019
areas c.e , Mc"
�
Job Site Address: p cCLU - � �l ed City/State/zi h A
Attach a copy of the workers' compLi
ensation 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 ce u_nder t urns and penalties of perjury that the information provided above is true and correct
Soma mre �'/'�Gf�- Date
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 M
Worker's Ct moenaation and Erriolover's Llawow polis
Ali
rkshire Hathaway AmGUARD Insurance Company-A Stock Co.
y Polley Number R2WC98B573
Insurance U A R D Companles RanaweNCCI No.l of [21873]
Policy Information Pass(AR)
[11 Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit B 16 NORTH ELM ST
South Hadley,MA 01075-2351 Westfield, MA 01085
Agency Code: MATIER30
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 folkming 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 IIabIIRy 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-WC200306B
D. This policy Includes these endorsements and schedules:
See Extension of Information Page-Schedule of Foran
(4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual Of Rules,
ClauMcations, Rates,and Rating Pians. NI required Information Is subject to verification and change by
audit. (Continued on another page)
Total EsUmatad Policy Premium ; 10,852
TOW Sumekaryq/Aeaaasments $ 389.00
Total FAgmabd Cwt 11 241.00
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Home Improvem tractor Registration
Type LLC
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SOUTH HADLEY,MA 01075 A
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351 NEWTON ST
SOUTH HAIXEY, OfOf5 UndelcacYSfary Not valid without Signature