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17C-149 (7) 110 HIGH ST BP-2017-0236 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map-Block: 17C- 149 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: INSULATION BUILDING PERMIT Permit BP-2017-0236 Project# JS-2017-000395 Est.Cost:$2311A7 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(sq. ft.): 5619.24 Owner: NASH PHILLIP H Zoning: URB(100)/ Applicant: GREEN COLLAR LLC AT: 110 HIGH ST Applicant Address: Phone: Insurance: 7 WARNER ST (413) 532-1817 SOUTH HADLEYMA01075 ISSUED ON:8/25/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: Air sealing and insulation 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: FeeTvpe: Date Paid: Amount: Building 8/25/2016 0:00:00 S65.00 212 Main Street.Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner RPC711 -.._. ' Department useonlyity of Northampton Status ofPermit: AUGAIAT 24 L Li!:! Building Department Curti Cut/Driveway Permit 212 Main Street Sewer/SepucAvalability Deur or auisu Room 100 Weter/Well AvadgbiBty eomnnr.arOn h1c,N"., Northampton, MA 01060 Two Sets of StructuralPlans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION 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 II o --I--116-41 Cr Map Lot Unit ilCka- MLS'cnoc,-Z Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: FI1I Nks rt Ilo hl4_11 ST T r.1^. NIA- 7)1n 6Z Name(Print) Current Mailing AddressZ 5c( ll-TCPc-t't,D ERM Telephone (e- `,/13) Z r . 32 32 Signature 2.2 Authorized Agent: Green Collar,LLC 7 Warner St. South Hadley,MA 01075 Name(Print) Current Mailing Address 413 532 1817 Signature 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(8) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Z-3/ L ' t— Check Number //SS This Section For Official Use Only Building Permit Number: Date Issued' Signature: S 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 trilled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage °o - Open Space Footage (Lot arca minus bldg&paved parking) #of Parking Spaces Fill: (volume&location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW trX YES O IF YES, 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 DONT KNOW Gl< YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 O X IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition liReplacemant Windows Alterations) L i Roofing ED Or Doors 0 1�,� Accessory Bldg. El Demolition New Signs [DI Docks IO Siding(p] Other II#u't Brief DescripC�tion of PropDosed Work: INSULATION/WEATHERIZATTON Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes ,X_No Plans Method Roll -Sheet Oa.If New house and or addition to existing housing, complete the following: 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 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 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cettar 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 SEE ATTACHED DOCUMENT as owner of the subject property hereby authorize Collar,LLC to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED DOCUMENT 06//6/-7 /4 Signature of Owner Date Steven Eckman ,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. Steven Eckman Print Name 067/b/Xo'6 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: CS-108817 Robert Calhoun License Number 8/23/2018 Address Expiration Date 390 Newton St. South Hadley, MA 01075 Signature Telephone /J 413 532 1817 9.Registered Home Improvement Contractor, Not Applicable ❑ Company Name Registration Number Green Collar,LLC 181415 Address Expiration Date 7 Warner St. South Hadley,MA 01075 Telephone 413 532 1817 4/1/2017 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 Dwellings ofonc(I) or two(2)families and to allow such homeowner to engage an individual for hire who dues not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.35.1. 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 in 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 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 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 N � 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 transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant ,_P o City of Northampton -• Massachusetts 4s7. x ;. 4 Olt DEPARTMENT OF BUILDING INSPECTIONS 212 Naim Street • Municipal Building Northampton, !A 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner NV" HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill). sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required)and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected If the homeowner hires other trades to perform work (electrical, plumbing &gas)the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents = �.—I 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: 7 Warner St 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 3 4. ❑ I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for mc in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance./ 9. ❑ Building addition required.] 5. 9 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their I I.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required.]p c. 152, §I(4), and we have no employees. [No workers' 13.® Othednsulation/Weatherization comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy information. *Homeowners who submit this affidavit indicating they are doing all work and that hire outside contractors must submit a new adidacit ind bating 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 far my employees. Below is the policy and job site information. Insurance Company Name: Berkshire Hathaway Guard Insurance Company Policy#or Self-ins. Lic.#: R2WC652666 _ Expiration Date:9/23/2016 Job Site Address: I t C) H 15 k $ j— City/State/Zip: rxe mCi Md 0/o6 a 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 51,500.00 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 ode th pains and penalties of perjury that the information provided above is true and correct Signature: Date: chi/7G/Z-0t6 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia RISE `' . b Mama Road,unit 3 I Canton,MA 02021 I 330402-8335 ENGINEERING win viaSMginsedng.com s _r.Y..::..rm. OWNER AUTHORIZATION FORM I, \Au 0716-91N (Owners Name) owner of the properly located at ll© 5l (Property Address) nitt( fes sM� (DCL ProluertY hereby authorize (Subconnbactor) en 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 QL Owners Signature Date S an -.. .. ...wo d "nand of Minding Regulations arM.Standards License: tS-108817 Construction Supervisor _ ROBERT CALHU �y g 390 NEYROR 1I..M 1J__3~.. Expirat%N' Commissioner 9&/233/2912 _ �/e .= tcrrr-alrcrtcw>ea/t% G zr:irzekterl _ Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5 170 Boston. Massachusetts 02116 Home Improvement Contractor Registration Registration: 181415 Type. LLC Expiration: 41112017 TMS 264318 GREEN COLLAR LLC, STEVEN ECKMAN 7 WARNER ST -.. _- ._... __..... . __. SOUTH HADLEY, MA 01075 Update Addrrss and return card.Mark reason for change. ', Address Renewal — Employment :- Lost Card .. Office of Consumer Affa n&Business Regulation License or registration valid for individul use only ti HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �egistradon: 181415 Type. ORice of Consumer Affairs and Business Regulation JExpiradon: 4/1/2017 LLC 10 Park Plaza-Suite 5170 Boston,MA 021]6 GREEN COLLAR ILO. STEVEN ECKMAN 7WARNER ST SOLI H HAUL.EY MA 01075 w - ""` Uodenccrcmr. Not valid without signature e BERKSHIRE HATHAWAY Worker's Compensation and Emoloyer'S Liability Policy It/4 GUARD INSURANCE COMPANIES AmGUARD Insurance Po cy Numbertock Company R2WC652666 Renewal of NEW NCCI No. [21873) Policy Information Page (AR) i[1j Named Insured and Mailing Address Agency GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC. 7 WARNER STREET 16 NORTH ELM ST SOUTH HADLEY, MA 01075 Westfield, MA 01085 Agency Code: MATIERIO a Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (L _ /kf • �.� [2] Policy Period From September 23, 2015 to September 23, 2016, 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 $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit 5500,000 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 $ 5,144 Total Surcharges/Assessments $ 275.00 Total Estimated Cost $ 5,419.00 'N7ERNALUSE......Qii Page - 1 - Information Page MGA : 4t2WC652666 WC 000001A Date 09/30/2015 nANOTE Issuing Office: P.O. Box A-H, 16 5. River Street,Wilkes-Barre, PA 18703-0020 • www.guard.com