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17A-008 (3)
39 LEENO TER BP-2017-0589 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 17A-008 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-2017-0589 Project# JS-2017-000954 Est.Cost: $3415.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grow): GREEN COLLAR LLC 108817 Lot Size(so. ft.): 13503.60 Owner: KACZENSKI JOHN J&BARBARA A Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: GREEN COLLAR LLC AT: 39 LEENO TER Applicant Address: Phone: Insurance: 7 WARNER ST (413) 532-1817 WC SOUTH HADLEYMA01075 ISSUED ON:10/26/2016 0:00:00 TO PERFORM 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 Signature: FeeType: Date Paid: Amount: Building 10/26/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0589 APPLICANT/CONTACT PERSON GREEN COLLAR LLC ADDRESS/PHONE7 WARNER ST SOUTH HADLEY (413)532-1817 PROPERTY LOCATION 39 LEENO TER MAP I7A PARCEL 008 001 ZONE R1(100)/URA(I00)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 'fes//C1 Fee Paid (/ Tvpeof Construction: INSUL THERIZATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108817 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management D olitio, Del // /0 -; 6-/1( �. y: re of Bui ding I -rcia Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning& Development for more information. (2( RS� /� far`( cr Enc."( Pe( t 1 Tl /-. Department use only City of Northampton Status of Permit Building Department Curb Cuuoriveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability 7.a; h % Northampton, MA 01060 Two Sets of Structural Plana `� phone 413-587-1240 Fax 413-587-1272 Plotlsae Plans / Other Specify gYPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1Property Address'. This section to be completed by office 3S Le enc Ter 0.02 Q Map Lot Unit f7---'kZone Overlay District r 0 ce n C e / /\,1A' 00 Co 2 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Jo4.n \< ecLeASki -- 1 Leeio Terrace Name(Print) Current elephoneMallin Address J /A 9 clenSz See Akkecbe.. ac0M-e-�,# �/ Y Signature 2.2 Authorized Agent: Green Collar, LLC 7 Warner St. South Hadley,MA 01075 Name(Print) Current Mailing Address: — 7------ — 913 532 1817 Sign- re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 3 j[ ( (a)Building Permit Fee I J.5 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee • 4. Mechanical (HVAC) 5. Fire Protection �pNS 6. Total=(1 +2+3+4«5) —3/y / � Check Number hvo '/ c This Section For Official Use Only Building Permit Number: DateIssued: Signature: 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 filled in by Building Department Lot Size Frontage Setbacks Front Side L: R L: R: . Rear Building Height 13Idg. Square Footage % F - Open Space Footage (Lot area inlnus bldg&paved parking) #of Parking Spaces Fill: ._ . ___. o.,lume&Incatiom r.... 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 YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW ® 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 ®X 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 (3 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 e 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 n Addition ❑ Replacement Windows Alteration(s) I 1 Roofing I I Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs Ill] Decks [q Siding[El] Other pizpX Brief Description of Proposed Work: INSULATION/W EATHERI ZA'I'I ON Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a.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 cellar floor below finished grade N Will building conform to the Building and Zoning regulations? Yes No I. Septic Tank City Sewer Private well City water Supply SECTION Ta-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 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 1111111111.111 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 6 ZZs-//6- Sign;-e 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 413 532 1817 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Green Collar, 1,LC 181415 Address Expiration Date 7 Warner St. South Hadley,MA 01075 413 532 1817 Telephone 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 of one(I) 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 108.3.5.1. 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 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 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: 1� Building permit number: A Name of Permit Applicant Date Signature of Permit Applicant RISE60 Shawmut Road, Unit 2 I Canton, MA 02021 1339-502-6335 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM k 0 � z-e. k (Owner's Name) owner of the property located at: `f Cr % rC Leif 1 1�- -A2"� (Property Address) . (Property Address) hereby authorize Gell 61(c r- LEc (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. X %IH A [, owner. 'ignatur_ Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 600 Washington Street 41 � ;.artt l Boston, MA 0211 1 c44,:z=J`'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizzbonnndividuall: Green Collar,LLC Address: 7 Warner St City/State/Zip: South Hadley, MA 01075 Phone N: 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(fill) 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 me in 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 officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] l' c. 152, 81(4),and we have no employees. [No workers' 13.© Othednsulation/Weatherization comp. insurance required.] *Any applicant that checks box al must also fill out the section below showing their workers compensation policy information. *Homeowners who submit this affidavit indicating they arc 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name_Berkshire Hathaway Guard Insurance Company Policy#or Self-ins. Lie. #: R2WC727792 Expiration Date: + 9/23/2017 e Job Site Address: 3 [ tee:I C l e rotc_e _ City/State/Zip: �1OSefCC / /it4 oto 6z 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sgnature: Date: t�/2$— �-G Phone#: '13 532 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 Employer's Liability Policy Insurance Company - A Stock Co. AmGUARD Berkshire HathawayPolicy Number R2WC727792 jet GUARDInsurance Companies RenewalNCCI No. [21873] Policy Information Page (AR) [1]Named Insured and Mailing Address Agency i, GREEN TR LLC TIERNEY INSURANCE AGENCV, INC. 7 WARNER STREET 16 NORTH ELM ST SOUTH HADLEY, MA 01075 Westfield, MA 01085 Agency Code: MATIERIO Federal Employer's ID 47-1041086 Insured is Limited Liability C LLC)C - f) r(IL.Lifitt41/477 [2] Policy Period < From September 23,2016 to September 23, 2017, 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 G 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 arid, 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 $ 5,749 Total Surcharges/Assessments $ 299.00 Total Estimated Cost $ 6,048.00 !-NTERNALUSE__K8 Page- 1 - Information Page MGA R2WC727792 WC OOOOOlA Date : 09/14/2016 MANOTE Issuing Office: P.O.Box A-H, 16 5. River Street,Wilkes-Barre, PA 18703-0020 s www.guard.com ivmassacnuyuns vepann ten,of room-aalety Board of Building Regulations and Standards license. CS-408817 E Constructor,Stmervtsor ,,a ROBERT CfLL.MGIBA 3S SOUTH A TH NWOEtiY . N-q-�n ExpvatOn, Commissioner O8120R04$ Office of Consumer Affairs and Business Regulation ' 10 Park Plaza - Suite c 170 Boston. Massachusetts 02116 Home Improvement Contractor Registration Repisttalien 181415 Type LLC ExUirOtlon: 4/1/2017 Tr/ 264318 GREEN COLLAR LLC. STEVEN ECKMAN 7 WARNER ST - _.. ---_ __...__. -. . ... SOUTH HADLEY. MA 01075 - - - - --- -- - Gpdatet address and r tut a card Hak r ,von for change. "' M1ddress - Renewal - Emplov meat "- 1 os (ard __ Ofice of Cone u'nrtain SB nuns Regulaann Lic¢nse or registra non valla for ludfvldol use onh' ioME IMPROVEMENT CONTRACTOR trelon the xp tetiun date. If round return in. V&e91s4rattom 181415 TYPO- Mike ofCo _amer Affairs and Insiness Regulation 4 �.Expiration: 4/1/2017 _LC 10 Park Plaza-Buil¢5170 Boston,MA 0211E GREEN COLLAR LW. .__,ESN ECrVAN T;A2h ER S', _. s;.4. TJTH AL .-.Y MA 01075 t de neyreta h' Not valid withoutusignature