11C-037 53 FLORENCE ST BP-2018-1130
GIS x: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-037 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cawgorv: INSULATION BUILDING PERMIT
Permit 4 BP-2018-1130
Project d JS-2018-002032
Est. cost: $5525.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Suc(sa.n.): 21518.64 Owner: ELLIOTT ERIC I
zoning: URA(100) Applicant: GREEN COLLAR LLC
AT.- 53 FLORENCE ST
Applicant Address: 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 WORKADD 14" CELLULOSE TO 468 SQ FT 11" TO 624
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:
FeeTvoe: Date Paid: Amount:
Building 5/t/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Z n >:lA.(R�tr`C1T�
RECEIVED Daparb �drnsa«*
Cit of Northampton Status of Permit `
But Jing Department Curb Ctnlorivewey Parnnit
APA 3 0 20182 12 Main Street sewenseptieA
Room 100 WaterlWa3 Avalabill
orth impton, MA 01060 TM Bass Ofsbuchsd Pf9hg
DEPT OF 6UILDING IOGPECTi�rj�_5 -1240 Fax 413-587-1272 Povske,Rai_
NORTHAMPTON,MAAY/AS8
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
Map G
Lot O✓ / Unit
Zone Overlay District
Elm SG District CS Distinct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ienr"e- /607� S3 r�(ort^ Ce 1r>4
Name(Print) Current Mailing Address:
Y�� Zw �JL!/�EC/j Telephone
Signature
2.2 Authorized Agent:
Green Collar,LLC 3 Main St.Unit B.South Hadley,MA 01075
Name(Print) Current Mailing Address'.
-- — 413 532 1817
Signa[ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by emet applicant
1. Building (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+q+5) Check Number
This Section For Official Use Only
Building Permit Number. Dale
Issued:
r
Signalur . l
Building annissionerinspector 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 LR'. U R:
Rear
Building Height
Bldg, Square Footage
Open Space Footage
(lot arca minus bldg&paved
,kin
4 offiarking Spaces
Fill
volume&Lorauio
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 R)X YES O
IF YM 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(Gearing,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 Stonn Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding Other[IYI]X
Brief DescrieU y of Proposed // (l � j rr
Work_ INgULATIVN/WEATHERIZATION ICL ✓ Wi 7 t/ j/ .�
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
Sa.it New house and or addition to exiatina housing-Complete the followinm
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?
it. Proposed Square footage of new construction. Dimensions
a. Number of stones?
f. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fl.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 Owner / Date
I, r�!!e!7 (_Wit'n ,as Owner/Authorized
Agent hereb 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.
�7-CiG2(� �Lr�vL�C/L
Print Name
Signature�lo wner/Ag�? Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nam.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 Nome hnmmi ment Contractor, 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,§25C16))
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(1) or two(2)famines
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 1083.5.1.
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 Uable 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.
ty
Address of the work: �3 T [ Mcd—'7 c-'t– f;zv //
The debris will be transported by: /LILA -7 /j/A `� fe
e 6,,,13
The debris will be received by:
Building permit number:
Name of Permit Applicant
S
Date Signature of Permit Applicant
Cnlutnla Gas°
of Masskht.lsetts 60 Shawmut Road, Unit 2 Canton, MA 02021
A NLS 0o nv
OWNER AUTHORIZATION FORM
I, Eric Elliott
(Owner's Name)
owner of the property located at:
53 Florence Street
(Street)
Leeds, MA 01053
(Town, State, Zip) _-
hereby authorize p� C
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain abuilding
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.
/ Cubmer - 2'v7' Signature
-Sign Date
04/04/2018
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
vi 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. 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.® 1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E] New construction
2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an aci employees and have workers'
Y capacity.tY 9. E] Building addition
[No workers' comp. insurance comp, insurance.
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t e. 152, §1(4), and we have no
employees. [No workers' 13.[Sj Othednsulation/Weatherization
comp. insurance required.]
"Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContraetors 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:_ AmGUARD Insurance Company -A Stock Co.
Policy#or Self-ins. Lic.#: R2WC855214 / Expiration Date: 9/23/2018
Job Site Address: - Rwe/(f e— City/State/Zip: leeC//
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 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 pains and penalties of perjury that the information provided above ivvttrrue andel correct
Sianat m Date,
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 Poliev
AIUARDCompanfes
rkshire Hathaway AmGUARD Insurance Company-A Stock Co.
Y Policy Number R2WC858214
Insurance Renewal or NlEW
NCCI No. (218731
Policy Information Page(AR) , r[
Ell Named insured and Mailing Address Agency �•..T
GREW COLLAR LIC TIERNEY INSURANCE AGENCY,INC.
3 MAIN STREET UNIT a 16 NORTH ELM ST
SOUTH HAD1EY.MA 01075 Westfield, MA 01085
Agency Code: MATIER30
Federal Employer's ID 47.1041086 Insured is Limited Liability Co.(LLC)
[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 Insurence-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
C. Refer to Residual Market Limited Other States Insurance Endorsement-WC2003060
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` 13,325
Total Surcharges)Assessmenfs $ 584.00
Total Estimated Cort 13 909.00
ItlIMM USE_qH Page- 1 - Intermarket Page
MW :R2WC855214 WC D00001.0,
pate : 10/0212017
MAMOTE
Issuing Office:P.O.Box A-H,16 S.River Street,Wilkes-Barre,PA 18703.0020 a W Ww.9uard.com
Masswri.setts Department of Paolic Sates,
Board o1 Building Regulations and Stands
License.CS-108817
ROBERT CALHO N!
3116 NEWTON ST
SOUTH HAD EY MA 61076
r—j✓:n (A—
Commissioner 01123101"
c_%`ie CCa�na>aayrusea��fi a�C%I�GaJ;lcac�ivae�s
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type LLC
GREEN COLLAR LLC. 181415
3 MAN ST.UNrT B. E),llration. 0313132018
SOUTH HADLEY,MA 01075
Usher Address and r,Aurn Qe%L Mark Nissan M dmg&
sc+, a awas _ ❑ Address 0 R,enswel ❑Enmloyn ent ❑t.ost Card
i/.. 't........,..,.a/.,/^/G,....
HOME IMPROVEMENT:LLCONTRACTOfi ewers ifte"Wadordala. N bund mly
nPE:LLC ewers of Co suMbrtdatw 8/oumness to:
_ 8181415 E� OMa of Consumer Affairs WW Business Rsar/etlui
181115 00/31,2119 10 Petit Plan•SMM 61]0
''6 EEN COLLAR LLC. BesMn,MA 02116
STEVEN ECIGIAN \fctcTe,,.a--
SMNNST.UNITB. U r
SOUTH IIADLEY,MA 010]5 UIIdBnBC(efBly NOT VeIM without BI9nB111T6
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