17C-126 (5) 297 BRIDGE RD BP-2017-1459
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I7A- 126 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
Pennit# BP-2017-1459
Project# JS-2017-002424
Est.Cost:$4525.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 21780.00 Owner: OUIMET EUGENE.1&AMY JO SULLIVAN
Zoning: URA(100)/ Applicant: GREEN COLLAR LLC
AT: 297 BRIDGE RD
Applicant Address: Phone: Insurance:
7 WARNER ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:6/16/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 10" CELLULOSE TO 1748 SQ FT ATTIC
FLAT
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 6/16/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Supe0 3r- L
File NBP-zm7-1459 Hat- 'nal ,
APPLICANT/CONTACT PERSON GREEN COLLAR LLC — ----- - - - ----
ADDRESS/PHONE 7 WARNER ST SOUTH HADLEY (413)532-1817
PROPERTY LOCATION 297 BRIDGE RD
MAP I7A PARCEL 126 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
(.--€'ICrLOS REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid N'
Building Permit Filled out
Fee Paid
Typeof Construction: ADD 10"CELLULOSE TO k4,8 SO TTIC FLAT
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
L FORMATION PRESENTED:
_Approved 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
Demolition Delay
Al _ _ E1619
Signature of Building O'ficial -1"1"
�" 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.
plu S e Nit( (erw1: 4,0 Gree Ca
Department use only
---�_ City of Northampton Status of Pe , ,
Building Department Curb Cut/Driveway Permit
- -1 212 Main Street Sewer/Septic Availability
JUN 13 �if!( h4 Room 100 Water/Welt Availability
, �
Northampton, MA 01060 Two,Setsof Plans
6 -_p ne 13-587-1240 Fax 413-587-1272 PlotlSRe Piens
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address.
q U This section to be completed) � by office
r7 r ' Jyp a I Map /TA Lot act Unit
_/ ✓ C Zone Overlay District
1 o C e •1 C 2 hV\ O I o 6 2 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 0r- �
Amy - 3o _CcAuAry Xp
17 RJ ( �Io nct
rec ,. t4 Cr o62
Name(Print) Current Mailing Address.
�� 4, 3 n7 3855
fer 4 �,/ (-e I net-ca440/\ Telephone
Signature
2.2 Authorized Anent:
Green Collar,LLC 3 Main St. Unit B. South Hadley, MA 01075
Name(Print) Current Mailing Address.
_- � 413 532 1817
Si re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building V r2 (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) �/S2 V Check Number /qoJr iZO
This Section For Official Use Only
Building Permit Number: Date
Issued.
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 fined in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: I,: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
of Parking Spaces
Fill:
(sclume&Location)
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 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 ex YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O 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,r�excavation, or tilling)over 1 acre or is it part of a common plan
tCY
that will disturb over 1 acre? YES O NO 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [(] Siding OD] Other[Gi7]X
Brief Descri tion of Pro osed
work. INSULATION/WEATHERIZATION ,.QMl I C " c+ ((close -,.w 17 (13. 5>{{ f
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
ea. 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
k. 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
I, 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 Ownerwnfer/' [ Date
11111111111.
/T'OO',',n "- ,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.
1]&, 4- Go-k'N'LRC
Print Name
Si.-.,iof Owner/Agent Date S 2 3 /7
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
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. Recleaned Homo—Improvement Contractor: Not Applicable 0
Company Name Registration Number
Green Collar, LLC 181415
Address Expiration Date
3 Main St. Unit B. South Hadley, MA 01075Telephone 413 532 1817 3/31/2019
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.. .. . N No ❑
11. - Home Owner Exemption
The current exemption for"homeowners' was extended to include Owner-occupied Dwellings of one(I) or two(?)families
and to allow such homeowner to engage an individual for him 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 hershe 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 ard/or fans
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 he
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on Ihe job site will he required from time to time during and upon
completion of the work for which this permit is issued.
Also he 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 he 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 re -ived by:
Building permit numb-r:
Name of Permit A ppli, ant ,41111
lir
Date '.ignat e of Permit Applicant
1
RIs E 00 Shawmut Road,Unit 2 I Canton,MA 02021 1339-5024335
ENGINEERING www.R1SEenglneering.com
OWNER AUTHORIZATION FORM
(Ow1(ers Name)
owner of the property located at:
Irl X180
Property Address)
kolZQuV..P 14. 4. 0Lob
(Property Address)
hereby authorize C7y" Gj �
(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.
�• t
.r_g&
• ers Signatu � _ ..
tl \�
Date -'
_ _..___-•-____�J
'\\ The Commonwealth of Massachusetts
Department of Industrial Accidents
_ tom/
Office of Investigations
600 Washington Street
Boston, MA 02111
i3-0," 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: 3 Main 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.X1 I am a employer with I 4. ❑ I am a general contractor and 1
employees(full and/or part-time).*
have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8, ❑ Demolition
working for me in anycapacity. employees and have workers'
6 P Y 9. ❑ Building addition
[No workers' comp, insurance comp. insurance.,
required.] 5. ❑ We are a corporation and its 10.11 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ l am a homeowner doing all work
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] l' c. 152, §I(4),and we have no
employees. [No workers' 13.1X] Otherinsulation/Weatherization
comp. insurance required.]
*Any applicant that checks box RI must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such_
leontracmrs 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. It 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,#: R2WC727792 Expiration Date:_ 9/23/2017
Joh Site Address: 2 l 7 U 1,‘,43-e- 1`v J City/State/Zip: “.�n c e i /I"z'I�j
c(O C ?
Attach a copy of the workers' compenation 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 5250.00 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 and penalties of perjury that the information provided above is true and correct
Signature: —_. . Date: s z r 1
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 Ems/lover's Liability Policy
Berkshire Hathaway
AmCUARD Insurance Company - A Stock Co.
l .�a.�, Q n Insuran e
PolicyRenewal of R2WC652666
fid 3 t4I%V Companies NCCI No. [21873]
Policy Information Page (AR)
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC; TIERNEY INSURANCE AGENCY, INC.
3 Main St. Unit B. 16 NORTH ELM ST
SOUTH HADLEY, MA 01075 Westfield, MA 01085 (1
Agency Code: MATIERI0f
Federal Employer's ID 47-1041086 Insured is Limited Liability C LLC)/4 � „
/01"
[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 (3jA. 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
It{Tr_pB,46.4E€_X% Page- I - Information Page
MGA R'WC727792 WC 000001A
Date :09/14/2016
MANOTE
Issuing Office: P.O. Rex A-H, 15 S. River Street,Wilkes-Barre, PA 18703-0020 •www.guerd.com
pp '.lassachusetts Department St PJDhC Sate
Board of Buitding Regulations and Standards
License CS-108817 t" $
if.r*t? x
ROBtRT CALHOtm
390 NEWTON ST ,e
SOUTH HADLEY MA 01415 -"
r'-'1.-."r'-'1.-." V{ -- Ex,.• 2 ,•
Commissioner 0812312018
_ 7`LC' 0 inn11Y71 wea/t% C/�C'l' I',isrta4lG P t6
,
10:H5•;
', Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LW. Registration: 181415
Expiration: 03/31/2019
3 MAIN ST.UNIT B.
SOUTH HADLEY,MA 01075
•
Update Address and return card. Mark reason for change.
seg. 6 zomDs-
0 Address O Renewal 0 Employment 0 Lost Card
• Office of Consumer Affairs a Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
? $eaistraton Eapimtloq Otice of Consumer Affairs and Business Regulation
1‘C.... 181415 03'312019 10 Park Plaza-Suite 5110
GREEN COLLAR LLC. Boston,MA 02116
STEVEN 3 MAIN ST UNIT B. \� Z
SOUTH HADLEY,MA 01075 undersecretary Not valid without signature