31A-272 (7) 23 DRYADS GREEN ST BP-2020-0095
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 3]A-272 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-2020-0095
Project# JS-2020-000163
Est.Cost: $4100.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sg.ft.): 33541.20 Owner: SULLIVAN VIRGINIA M
Zoning:URA(100)/ Applicant: GREEN COLLAR LLC
AT. 23 DRYADS GREEN ST
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413)532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:7/29/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 6" LAYER OF R-19 TO 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 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:
FeeTvue: Date Paid: Amount:
Building 7/29/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
70 - !5
Dep
City of Northamptorf Ey C I V C}
Building Department
212 oom 00JVL 2 5 2019 I SULATION
Northampton, A 1060
phone 413-587-1240 axr2V13 Q72�r,zPFc ioNs
NORTHAM; ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
171-1?1
Map Lot � Unit
Zone Overlay District
Eim St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
VicAAo sUll( VC,0 2-1 DYlAao(.8 Oc en S+-
Name(Pr' ) Curre tIMq `Q ingress:
S oW C. Telephone -1
Signature
2.2 Authorized Agent:
Uretn I n,( AAbd,
Name(Print) Current Mailing Address:
0(_�A 141'�)- 532-I8I'�
Signa wrei Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �y 1 0 v (a)Building Permit Fee
2. Electrical i V (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee / r
4. Mechanical(HVAC) / Q�7
5. Fire Protection v
6. Total=(1 +2 +3+4+5) 910 0 Check Number
This Section For Official Use Only
Date
Building Permit Numb r: Issued:
,7
Signature:
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: �Z� r � 1 W r I V� -
License Number
,,%I Ak d La44 I AA4 0105 t- 23-2M"10
Address J, Expiration Date
SUjaklre Telephone
9.Realstered Home improvement Contractor: Not Applicable ❑
Qra1) (Tar UC, ��-I �IF1
Company Name Registration Number
'SSI p) WkdI 1. . N-A DO-) S �2)� -2-4)21
Address Expiration Date
TelephoneLgh b32 1 11
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: INSULATION ONLY
n.s--aAI �« aq er 01(2 Q tcl c c s �- Ce(W W r5oo
'DIP
I, cjran �c, �1.c i 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.
Print N
1 -22't
Si re of Owner/Agent Date
I, CS'L.7L as Owner of the subject
property
hereby authorize ����QnWlw( LLC i
to act on my behalf, in all matters relative to work authorized by this building permit application.
Skk 6,11WW dbWiv A t 1 ::f-LM
Signature of Owner Date
City of Northampton
Massachusetts
�G
DEPARMNT OF BUILDING INSPECTIONS �' M
212 Main Street • Municipal Building yvd cD�
Northampton, MA 01060
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'�U a�No A f Ahkh TA-60 0 Est. Cost: 414 to 0
Address of Work: 2", p GLgL6 QJr4JA c t
Date of Permit Application: 01
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:
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
j •�'' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street •Municipal Building v6 Com,
Northampton, MA 01060
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:
(Please print hbuse number and street name)
Is to be disposed of at:
�Q xxk\kms MCS b.1fu++�011 :C � - ,,N�
Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(C6 - -
m pany Name and Address)
Sign a 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.
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Virginia Sullivan
(Owner's Name)
owner of the property located at:
23 Dryads Green Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize C-yk�n W�\ r
(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.
Owner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211 339-502-6335
www.RISEengineering.com
.� The Commonwealth of Massachusetts
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 J"L 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors ❑ 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. ❑ Building addition
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.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
tContractors 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 mate: 9/23/2019
Job Site Address: 221 C)in A C-1r f City/State/Zip:NWAk�ftjv� T� 41�
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 the pains and penalties of perjury that the inf n-ination provided above is true and correct.
Signa ture: .�
Date: h--�-
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 Compensaition and EmDlover's Liability Policy
11V*'Berkshire Hathaway AmGLIARD Insurance Company - A Stock Co.
7 Policy Number R2WC988571
Insurance Renewal of R2WC855214
1
GUARD Companies NCCI No. [21873]
r
Policy Information Paye (AR) 4f Id
[1)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: 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
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
INMNAI use XX Page- 1 - Information Page
MGA : R2WCM571 WC 000001A
We :09/04/2018
MANOTE
issuing Offices P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 a www.guard.com
,�' �;a e,d-�e 4 ell!4,
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 0 20M-0517
.��i-
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 �,Q
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
w
Commissioner
City of Northampton
� Massachusetts
R
r N
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building 0 �DO�
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 2-"-.) tMaAA &Cp Q� �-f .
Contractor
Name:
Address: ���` N Paul ooh �� U�ni�- a S �4aQllQ,�► �nA r�,o
City, State:
Phone:
Property Owner
Name: \11kc*I o I a Ru i 0 QCk n
Address: 0-1 Ua a0� S+-
City, State: N 41�'� j p V6 ffiq
1. kD (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature -
Date
R
E C E 9 W E
JUL 29 2019
Electric,Plumbing&Gas Inspections
Northampton,MA 01060
2019 '111/ ATHERIZATION
mass save BARRiR
Savings through enemy efficiency m n INCENTIVES
Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing
improvements.Before moving forward,please follow all the instructions below to remediate your weatherization barriers.
CUSTOMER INSTRUCTIONS
1. Hire a qualified, licensed contractor to evaluate and/or remediate the weatherization barrier(s).
2.Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)within 60 days of your Home Energy
Assessment to: RISE Engineering,60 Shawmut Rd,Unit 2, Canton, MA 02021
Or email to ColumbiaGasMAlnfo o RISEengineering.com.
3.The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check
will be issued in the event the amount exceeds the customer's co-payment amount.
4.Complete the recommended weatherization improvements.
FORMATIO' 01
Customer Name: Virginia Sullivan Client#or Site ID: 477816
Site Address: 23 Dryads Green Street City: Northampton State: MA ZIP: 01060
Phone Number: 919-622-9422 Email: SULLI.VAN@EARTHLINK.NET
Customer/Homeowner Signature: Date:
KAND TUBE Wf
NOB
To determine if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mass Save'
weatherization recommendations have been made:
kl Attic Fioor X Attic Wali g Attic Slope M Exterior Wall Ct'Basement 7 Other.______ _. _____—❑Other:
0 1 have performed my inspection and determined there is no active knob and tube wiring in the areas selected below.
XX Attic Floor N Attic Wall X Attic Slope R Exterior Wall IKBasement L Other: ❑Other:
9 1 have read and agree to the Terms and Corditions on the back of this form.
Contractor Name: .`"»few-YN �i �\e4e i –
Address: I `c j � City:r i ,DD(FIPtI State: I ZIPQ V,: 13
Company Name: Tr License Number: t_2I a i
Contractor Signature: Date:.L!K 7
High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level,
as measured in the undiluted flue gas,to below 100 parts per million(ppm).
Draft Failure:Contractor is to correct the draft in the selected flue(s).Refer to table on reverse for acceptable draft ranges.
CarbonHigh
Existing CO ppm: Revised CO ppm: Existing Draft Pa: Revised Draft Pa:
Heating System
Hot Water Heater
Other.
Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation.
❑ Heating System ❑ Hot Water Heater ❑ Other:
❑ I have performed my inspection and have corrected the items noted in the areas selected above.
❑ 1 have read and agree to the Terms and Conditions on the back of this form.
Contractor Narne:
Address: City: State: ZIP:
Company Name: License Number:
Contractor Signature: Date:
Continued on back
(page 1 of 2)