24A-049 (9) 133 BARRETT ST BP-2018-1131
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block:24A-049 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-2018-1131
Proiect# JS-2018-002033
Est.Cost:$3598.00
Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sp.lt.): 11238.48 Owner: HIDALGO KAREN
Zoning:URB(100)/ Applicant: GREEN COLLAR LLC
AT. 133 BARRETT ST
ApplicantAddress: Phone. Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:5/1/2018 0:00:00
TO PERFORM THE FOLLOWING WORK ADD 10" CELLULOSE TO 972 SO FT 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:
FeeTyoe: Date Paid: Amount:
Building 5/1/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use omly
I Ity of Northampton Status of Permit:
�Uilding Department Curti CWDrAewgyPermR
APB 32018212 Main Street SswerMaidleA
.I Room 100 WatedWeN AvaifabWity
�, —
Northampton, MA 01060 TSD S�gf Structur6l Plein.
neRr or owl r
PMPTOM1.^A - 87-1240 Fax 413-587-1272 PloVStte Plans
NORTH
011ier Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH
A ONE OR TWO FAMILY DWELLING
SECTION t -SITE INFORMATION ✓q
t.t Property Addr/efss: Map �hq?+ L. Q�
lo /pletedis offiUnit
Zone Overlay District y
Elm St.DisMct e5 District
-
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: / 2
k-cre� �. c[ d �4o X73 K -� '5;Z
Name(Print) Cunent Mailing Address'
Telephone
Signature /
2.2 Authorized Agent: Y5-( /L4"`Z4^ St
Green Collar,LLC 17Aein"Unit B.South Hadley, MA 01075
Name(Pool) Cunent Mailing Address:
413 532 1817
Signatur6 Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit aoDlicant
1. Building �^j Cf� G (a)Building Permit Fee
2. Electrical l J O (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection v
6. Total=(1 +2+3+4+5) 1 7 15 Check Number aa�
This Section For Official Use Only
Dale
Building Permit Number: Issued:
Signatur . lB
Bui n ommissionetllnspector of Buildings Data
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
no calumo to be filled in by
Building Dr orancnt
Lot Size
Fronts e
Setbacks Front
Side C: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Inr area minus bldg&paved
,,kin
N ofParking Spaces
Fill:
volume&Lowtioo
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 DON'T KNOW OX 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 excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO (g 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 WindowsAlleration]s) Roofing Q
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0) Other[MX
Brief DescneeULof Propyosed ^,� J f !r A� /
Work: INJULATIUN/WEATHERIZATION /-yam (0 �C /i(L X� Tz
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes __)L_No
Plans Attached Roll -Sheet
ea.M New house and oT addition to existing housing, cOnlglate 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?
J. Proposed Square footage of new consimction. Dimensions
e. Number of stones?
C Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschack 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 7a-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 Ow]n�eerrDate
1,
I, // �" `–� Q-\ 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 Name
Signature mar/A SIJ 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 SL South Hadley, MA 01075
Signature Telephane
413 532 1817
9.Realsbrad Heme hnprovement Contrii4or. Not Applicable ❑
Company Name Registration Number
Green Collar, LLC 181415
Address Expiration Date
3 Main St. Unit B. South Hadley, MA 01075 Telephone 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....... W No...... 17
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such homeowner to engage an individual for hire who docs 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,ar is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person ho 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 buildine 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 persons)
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: 1 -77 lzc'ir'r�— Y4.(
The debris will be transported by:
The debris will be received by: '11�11A
Building permit number: // /
Name of Permit Applicant s C. (Gs —
Date
�
Date Signature of Permit Applicant
G31umbia Gas
of Massachusetts 60 Shawmut Road, Unit 2 Canton, MA 02021
A NSeui Camp�ny
OWNER AUTHORIZATION FORM
I, Karen Hidalgo
(Owner's Name)
owner of the property located at:
133 Barrett Street
(Street)
Northampton, MA 01060
(Town�State, Zip)
hereby authorize LSA� (a _
(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.
-Gusto re
") - �_- tZ-
-Sign Date
4/2/2018
The Commonwealth of Massachusetts
Department oflndustrial 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: 3 Main St. Uqit B.
City/State/Zip: South Hadley,MA 01075 Phone #: 413 532 1817
Are you an employer?Checkth appropriate box: Type of project(required):
1.91 1 am a employer with 4. ❑ I am a general contractor and I 6 E]Now construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 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' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.)
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 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 ❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.N Othednsulation/Weatherization
comp. insurance required.]
"Any applicant that checks box 4l must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
lCommcons 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 subcontractors have employees,they must provide their workers'comp_policy number.
7 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. Lie.#: /JR�2WC855214 Expiration Date: 99/23/2018
Job Site Address: 11/ /GAY/ f7z �q City/State/Zip:
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`u/nder the pains and penalties of perjury that the information provided above is true and ccoorrect.
Signature / _ Date !K/_0 T/1O
Phone#: 3 532 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 LlabllRy Policy
$ Berkshire Hathaway AmGUARD Insurance Company•AStock Co.
Y Policy Number R2WC855214
GUARDInsurance Renewal of NEW
Companles NCCI No. [21873]
Policy Information Page(AR) /,), r�
[3]Named Insured and Mailing Address Agency 1i.T(/)ffG..QQQ•..aaaO�GLL���aVVV
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY,INC.
3 WllN STREET UNIT B 16 NORTH ELM ST
SOUTH HADIEY,MA 01075 Westfield, MA 01085
Agency Code: MATIERSO
Federal Employer's ID 47-1041086 Insured is Limited Liability Co.(ILC)
[2] Policy Period
From September 23,2017 to September 23,2018,12:01 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 Rem[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 s 13,325
Total Surcharges/Asseumams $ 584.00
Total Estimated Cost 13 909.00
00I88M!ISE..Oh Page- I - Information Page
MW :0.2WCaaa21{ WC 000001A
wite :10102/2017
MANOTE
Issuing Oma:P.O.Box A-H, 16 S.giver Street,Wilkes-Barre,PA 15703-0020•srww.guard.mm
Massachusens Department or peon Safet:
Board of Building Regulations and Stand.
License.CB-108817 :..
ROBERT CALNOIN
08
3NEW=
SOUTH HADLEY 'A ,'078
NIZU CA— Ex"-a. 1
Commissioner 08,23,!018
&�eC mmg),tcaeccN 0/1 6A I"CW�
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. mon: 181415
N
3 MAST.UNIT B. E)praOon. 03/31/2018
SOUTH HADLEY,MA 01075
UpdaH Address and relem card. Mark Reason ter Change
sc.' o O Address O Ramwal O Swela"Re t O Lost Card
�- papa.!Cenrunr AllWeA Buenar RepulNm
:� 11011E NNIOVEMENT CONTRACTOR Registration velld for Individual use only
TYPE:LLC lieMretheeapleelrnaals, rNum b:
1 ElwlutivB Office of ConsumerAffairs and Buuraas Reguladm,
181415 0331=19 10Prk Plra-SUMS170
MEE_EN IXILLAR LLC, Boston,MA 02118
STEVEN ECIOAAN
3 MAIN ST.UNIT B. U e
SOUTH HADLEY,MA 01075 Undersecretary Not Val d without signature
r ..