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17C-041 (10) 63 SHEFFIELD LN BP-2017-1007 GIS tin COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-041 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-2017-1007 Project a JS-2017-001740 Est.Cost:$2800.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Cass: Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(so. ft.): 15725.16 Owner: CHODOS LEIGH Zoning: URB(I0o)/URA(0)/ Applicant: GREEN COLLAR LLC AT: 63 SHEFFIELD LN Applicant Address: Phone: Insurance: 7 WARNER ST (413) 532-1817 WC SOUTH HADLEYMA01075 /SSUED ON:3/7/2017 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: FeeType: Date Paid: Amount: Building 3/7/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner pt-cpt_c tte mg. I PE1A-er^ (r Tv Co JW t c-ft>R - 71-r/t r i s .� Green Collar, LW City .d Northampton matusat{tennh: 3 Mein St. Unit B. Builth- g Department CuthOu Dn it �y watt Ha4lep,MA 01075 ' 2 Main Street SelaodseptN; ,v' a-. Room 100 Wee Northampton, MA 01060 'two Setauf 5 ny r- I p 4one 413-587-1240 Fax 413-587-1272 PIOISlte Plans " a ° ������pp tV'aa — 7 T 1 Cklr'er SPedfy }., APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION IA Property Address: This section to be completed by office G 3 Si. €s,a.(b Lc, Map Lot Unit FGo.^?..nr t, / rt- p it rat_ Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2-1 Owner of Record: Le-is y to Ch., L- s Name(Print) ('� CarrMailin��dreq See....... i rt-E i� poc' Telephone � Stenotype 2.2 Authorized Agent: Green Collar, LLC 7 Warner St. South Hadley,MA 01075 Name(Print) Current MailingAddress: �- 413 5321817 8 l:' Signature Telephone SECTION 3•ESTIMATED CONSTRUCTION COSTS earn Estimated Cost(Dollars)to be Officrat Use Only completed by permit applicant 1. Building Z�C 2- 410 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from{6) 3. Plumbing BulldingPennitFee _.. 4. Mechanical(HVAC) 5.FireProtection -2-13t2. .10 6. Total =(1 +2+3+4+ 5) Check Number 1113 S This Section For Official Use Only ✓ Building Permit Number_.,_ Date - ed: Signature: \ ! —' 7 BuiMLr • missioner/Insppector of Bulldogs Date Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning ibis column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R L. R: . Rear _ ..._ Building Height -' - Bldg Square Footage ,o Open Space Footage n/o (Lot area minus bldg&paved parking) #of Parking Spaces -- -- Fill: (volume&Location) - --- .-. A. Has a Special Permit/Variance/Fin(d,in(gever been issued for/on the site? NO O DONT KNOW lJX YES O IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 DON'T KNOW 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 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 © NO O 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) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. tEl Demolition ❑ New Signs [0] Decks ED Siding[O] Other[OM Brief Description of Proposed Work: INSULATION/WEATHERIZATION 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 self 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 R.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. 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 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 -3/ 1/2 ,f7 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 L 311 /2.01'7 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 Signalurr aet Telephone 6?- )5.23 7i � 413 9.Reoistered Home Imoronemcnt Contractor. Not Applicable ❑ Company Name Registration Number Green Collar,1.LC 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 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 /4/`/2 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: 6 S/Na e (J L n The debris will be transported by: 47/4)- The debris will be received by: Mk Building k Building permit number: Name of Permit Applicant L [c 3l!/7-0(7 / ea— Date /--- Date Signature of Permit Applicant on The Commonwealth of Massachusetts t - Department of Industrial Accidents _y Office of Investigations 'c 600 Washington Street c k7 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): P. I am a employer with o9- 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 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 I I.❑ Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]' c. 152. §1(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 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: Berkshire Hathaway Guard Insurance Company Policy#or Self--ins. Lice#: R2WC652666 Expiration Date: 9/23/2016 Job Site Address:-(,? SrtE Y r I d)-0 t-p _ _ City/State/Zip: F-LocCNt.c'z /1-vt a 2&2 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 t e pal s and penalties of perjury that the information provided above is true and correct Signature: Date: 37t /Zo 17 Phone#: 413 532 1817 Official use only. Do not write in this area, to he 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 it: 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 bean 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 permitilieense applications in any given year, need only submit one affidavit indicating current policy information (if necessary)and under"Sob 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.govldia * Worker's Compensation and Employer's 6iability Policy �/� I AmGUARD Insurance Company-A Stock Co. B@CICS i• f �G�tll..lc�WcPolicy NumberR2WC727792 ,GUARD Renewal Companies NCCI No. 1218731 Policy Information Page(AR) [1]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: MATIER10 ^1�r Federal Employer's io 47-1041685 Insured is Limited Liabii' ) Zia (2) Policy Period From September 23,2016 to September 23,2017, 12:01 AM, standard time at the insureds mailing address. = (33 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 [37A. 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-WC2003068 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 $ 5,749 Total Surcharges/Assessments $ 299.00 Total Estimated Cost $ 6,048.00 ISEti u$E x% Page - 1 - Information Page M6A :R2WC727742 WC 000001A Date : 09/14/2016 MANOTE Issuing Office;P.O.Box A-H, 16 5.River Street,Wilkes-Sam,PA 18703-0020•www.guard.com massacnusests vepanment m ruunc Jatene Board of Building Regulations and.Standards License:(S-108817 [Construction Supervisor ROBERT CALfgW C.. 3 SSOOUT x ;gip M"a"c CA.-- Expi ate: Commissioner s621Ty ^��ae \Co?.rzr�rorru.ea/l ai. c Gd( . tze�ruuell Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 181415 Type: LLC Expiration: 4/1/2017 TTN 264318 GREEN COLLAR LLC. STEVEN ECKMAN --- """-- 7 WARNER ST '--. .---- -_----_— SOUTH HADLEY, MA 01075 - - - - - Update Address and return card.Mark reason for change. Address - Renewal —: Employment '-I Lost Card ,,. Office of Consumer Affairs&Business Regulation ov License or registration valid for individul use only SOME IMPROVEMENT CONTRACTOR before the expiration date If found return to: 'l 'Registration: 181415 Type: Office of Consumer Affairs and Business Regulation NSExpiration: 4/1/2017 LLC 10 Park PGus-Saife 51 i6 Boston.ML1 02116 GREEN COLLAR LLC. STEVEN ECKMAN 7 WARNER S- SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature RISE60 Shawmut Road,Unit 2 I Canton, MA 02021 1 339-502-6335 ENGINEERING' www.RlSEenglneering.com OWNER AUTHORIZATION FORM (Owners Name) owner of the propertyrt- locatedt a 1,,. 4./7i iZ ! /�L () /71 Nva (Property Address) O/ CP � (Property Address) hereby authorize i"ret=--r1 ((c. _ (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. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Owner' ignatuf 1/10/17 Date 6.2016