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44-096 (2) 430 ROCKY HILL RD BP-2020-0084 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:44-096 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-2020-0084 Proiect# JS-2020-000134 Est.Cost: $2982.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: - Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(sg.ft.): 35719.20 Owner: MADERA REBEKAH Zoning: Applicant: GREEN COLLAR LLC AT. 430 ROCKY HILL RD Applicant Address: Phone: Insurance: 3 MAIN ST UNIT B (41 3) 532-1817 WC SOUTH HADLEYMA01075 ISSUED ON.7/23/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 8 IN LAYER OF OPEN BLOW CELLULOSE TO 840 SQ FT OF ATTIC FLOOR 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'Deaartment 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: FeeType: Date Paid: Amount: Building 7/23/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _ Dep City of Northampton T Building DepartmentOR v A � � 212 Main Street SURoom 100 JUL zz 2019 LA TION Northampton, MA 01060 r' phone 413-587-1240 Fax - -1272 ONLY 'CUILDING!'1SPECTI APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLI ONLY 616 30— Sq SECTION 1 -SITE INFORMATION INSULA TION PERMIT 1.1 Property Address: This section to be completed by office �� mMap ' / Lot J -Unit— Zone nitZone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 4'helaah Nden q3% Hi II U. mno*)o Name(Print) CCuulrrent Mailing Addr s: O (�, _— t P 0_4461 G em Gw y�e n-t-— Te ephoon711)-44�a d►�v[2 Signature 2.2 Authorized Agent: 7 re I ICL r LLL 151 I f"--}tyvs_+ vYl�-1- _ S�cNIn H�iCI�P,rJI� Name(Print) Current Mailing Address: � - q(�-( -1 ii-1--) Sign Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) 2q it Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 7- ZZ-Z)q Building Commissioner/Inspector of Buildings / Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 1�Q11DQr+� hbl)(1 C License Number MA 0 (0-) S- a - 71 3 - Zo20 Address Expiration Date g li S�`�-t�T-1 Sig re Telephone 9.Reallstered Home Improvement Contractor Not Applicable ❑ Clr -en UkWr- LLC. tlktyt 5 Company Name Registration Number a)5t tt�nS� Vri� �a��h d 0S `13- 3 t - IJULt Address Expiration Date Telephone 4q -S32-(V(-) SECTION 5-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....... No...... ❑ Brief Description of Proposed Work NOTE: INSULA TION ONL Y OP oPen blow C AWIOs.e-, to F o r ( I)WAV==- `'�=� 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. `PTX?r+C(' tkh-),n, Print Name ) Sign uee.oreffgeJenf Date I as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Permit Authorization mass save Form Site ID: 3840844 Customer: REBEKAH MADERA owner of the property located at: (Owner's Name,printed) 430 Rocky Hill Rd Northampton MA 01062 (Property Street Address) (city) 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. Owner's Signature: �i Date: �' —c c _f C7 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Cafe Qnuk f ir- LL Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page I of 1 For Office Use Only Rev.102015 r City of Northampton Massachusetts �. w DEPAR2 NT OF BUXZDING INSPECTIONS 212 main street • Municipal Building Zvb a� Northampton, MA 01060 scy� `^�O AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion, improvement removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with �a corporation or LLC,that entity must be registered Type of Work: 1�S&kfttl/W.�, ��1�' ��j(�n Est. Cost: Z- Address of Work: 42�Q Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: -"kg 191 6, a en WW, LLCi ilk HI Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature _ City of Northampton /� •'� � Massachusetts r DEPARTMENT OF BUILDING INSPECTIONS 212 Main street •Municipal Building Northampton, MA 01060 ssw `10� Debris 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. The debris from construction work being performed at: 4Du VOILA (Please print house nujnber and street name) Is to be disposed of at: W'1LSeiA) C3 —`,' Please print name a d location of facility �T—a w� M� Or will be disposed of in a dumpster onsite rented or leased from: —(Company Name and Address) 01 Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts r Department of Industrial 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 Name (Business/Organization/Individual): 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.® I am a employer with l2 4. E] I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors �' E] New construction 2.El I am a sole proprietor or partner- ;:sted 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 ]0.❑ 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.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.© OtherInsulation/Weatherization 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 job site information. Insurance Company Name:_ AmGUARD Insurance Company - A Stock Co. Policy#or Self-ins. Lic.#: R2WC855214 Expiration Date: 9/23/2019 Job Site Address: 4 IRA,M ` City/State/Zip:. - MD- Ln AA40 9Z Attach a copy of the workers' con1pensation 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: .P4� 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#: Worker's Compensation and EmRlover's Liability Ppllr 111d"Berkshire Hathaway AmGUARD Insurance Company- A Stock CoInsurance . Policy Number R2WC988S71 GUARDCom antes Renewal of R2WC855214 P NCCI No. [21873] r Policy Information Paye (AR) [1)Named Insured and Mailing Address Agency GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC. 351 Newton St Unit 8 16 NORTH ELM ST South Hadley, MA 01075-2351 Westfield, MA 01085 Agency Code: MATIER10 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 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-WC200306B 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 $ 10,852 Total Surcharges/Assessments $ 389.00 Total Estimated Cost 11 241.00 IIY -RNAs USE XX Page- 1 - MGA :R2WC988571 Information Page om :09/04/2018 WC 000001A MAMOTE Issuing Office: P.O.Box A-H, 16 S. River Street, Wilkes-Barre,PA 18703-0020 0 www.guard.com -/-/ell J�e Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC GREEN COLLAR LLC. Registration: 181415 351 NEWTON ST UNIT B Expiration: 03/31/2021 SOUTH HADLEY, MA 01075 Update Address and Return Card. SCA 1 A 2OMM--05/17 .//ii yiviii.rv.rirvr�/�r�. ��iri•irir�ii-:r//.� 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 Exoiration Office of Consumer Affairs and Business Regulation 181415 03/31/2021 1000 Washington Street-Suite 710 GREEN COLLAR LLC. Boston,MA 02118 STEVEN ECKMAN - 351 NEWTON ST UNIT B SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature ® Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-108817 Expires: 08/23/2020 ROBERT CALHOUN 390 NEWTON STREET SOUTH HADLEY MA 01076 Commissioner C