24D-167 (6) 39 MYRTLE ST BP-2018-1132
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D- 167 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-2018-1132
Proiect# JS-2018-002034
Est.Cost,$1165.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Grou07 GREEN COLLAR LLC 108817
Lot Size(sp ft)7 6882.48 Owner: DWIGHT WILLIAM&ALIDA LEWIS
Zoning: URC(100)/ Applicant: GREEN COLLAR LLC
AT., 39 MYRTLE ST
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.•5/1/20180.00:00
TO PERFORM THE FOLLOWING WORK.ADD 2" RIGID BOARD TO 56 SQ FT KNEEWALL
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:
FeeTvpe: 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
REE D- DepMbnent tme mty
ity of Northampton Statue of Permit
Wilding Department Curt CuDDrnaxay permit
0 t v9 84 212 Main Street SewariSetalic,A '
Room 100 WaterrNell Avallabifiry
N hampton, MA 01060 Two sets of SirucaaaiP
DEPT.OF BUILDING INSPEGLiQe413587-1240 Fax 413-587-1272 PImtSBe PIWrB . .
NORTHAMPTON,MR 6M0kU�
Omer Specry
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION
1.1 Property Address: e
This section to be completed by offic
Sat M yr�-I� 5 / , {p Unit
OwnayDistrict
Elm St.District Ca Charlet
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: . �
Twill Lra q Zeu .f 3� M yl� 1'f
Name(Pont) Current Mailing Address:
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
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit a pliciant
1. Building / / / C'^ (a)Building Permit Fee
2. Electrical / (O -.J (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permit Fee M'!
4. Mechanical(HVAC) lJ
5. Fire Protection
fi. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: T/� B
Building issioneolospector of Buildings Data
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Acquired by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L. R' L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Wt area minus bldg&paved
parking)
If ol'Parking Spaces
Fill:
volume&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 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(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 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[o] Other[OMX
Brief Description of Proposed
workINSULATIONIWEATHERIZATION— /9L y
1
Alterapon 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.N New house and or addhion to existing housing, complete the following:
a. Use of building:One Family Two Family Other
b. Number of roams 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?
It. 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
1, 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, J �zen zr1,&,1di ,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.
?�Cvi Z�-e
Print Name
Signature oflOwnerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder CS-108817
License Number
Robert Calhoun
8/23/2018
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signaturel.Y/ Telephone
413 532 1817
9.Roulstmd Home lmprowmenl Conrraplor. 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,S 25C(8))
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)families
and to allow such homeowner to engage an individual fur 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-veer 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 maybe 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 Gencml 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: / �f
The debris will be received by:
Building permit number:
Name of Permit Applicant
/-Z
Date
Date Signature of Permit Applicant
Columbia Gas
or Massachusetts 60 Shawmut Road, Unit 2 Canton, MA 02021
A M4wMw CwnM�Y
OWNER AUTHORIZATION FORM
i, Lida Lewis ,
(Owners Name)
owner of the property located at:
39 Myrtle Street
(Street) _
Northampton, MA 01060
(Town, State, Zip)
hereby authorize (!: c7 �
(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 homeowners
responsibility to close out this permit by contacting their municipality at the completion of this work.
Customer ignat re
-Sign Date
4/3/2018
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Raciness/organizanoNlndividuaq: 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):
1.91 I am a employer with fp 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I 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 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. tight of exemption per MGL 12 ❑ Roof repairs
insurance required.] t a 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.
I 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 slate 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:_ AmGUARD Insurance Company - A Stock Co.
Policy#or Self-ins. LLiA
ic�.#: /h R2W/CC85521144 Expiration Date: 9//223/2018]
Job Site Address: l ( /'I t/��%�- > City/State/Zip:
AttacM1 acopy 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 the pains and penaldes of perjury that the information provided above is true and correct.
Signature' Date'
Phone#: 413 532 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: Planes:
Worker's Compensation and Employer's liability Poliev
al of NEW
AlUARDCompartles
rkshire Hathaway Am6UARD Insurance Company-A Stock Co.
y Policy Number R2WC855214
Insurance n NCCIRNo. (21873)
Policy Information Page(AR)
[i]Named Insured and Mailing Address Agency ///IIx l.Jl/ILLL000.RRKCCRRR77/VVV
GREEN COLLAR LIC TIERNEY INSURANCE AGENCY, INC.
3 MAIN STREET UNIT B 16 NORTH ELM ST
SOUTH HADIEY,MA 01075 Westfield,MA 01085
Agency Code: MATIERIO
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 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 acddent $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 the"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 $ 13,325
Total surcharges/Asaessmems $ 584.00
Total Estimated Cost 9 13 909.00
INIEW&05E _QH Pape-1 - InfomeWnn Page
MGA :R2WCa55214 WC 000001A
we :10/02/2017
MANOTE
Issuing Omce:P.O.Box A-H,16 S.River Street,Wilkes-Barre,PA 18703-0020 e W Ww.guard.c6ni
Massachusens Department of PdSltandS
Board of Building Regulations a
License. CS-106817
ROBERT CALHOUN
3H NEWTON ST
SOUTH HADLEY MA 01076
MZnn CA_ Ex'.-P. ., r
Commissioner Oa11L101t
'� � CJ6te Ctam,��ta�tti�ealt,<i a�C��:1ucLutselaa
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type LLC
GREEN COLLAR LLC. PAg : 181415
3 MAW ST.UNIT B. E10ralicn: 03131/2019
SOUTH HADLEY,MA 01075
Uands Addrna and maim wil. MMa rnnn Nr drrga
W., 0 sivas„ ❑ Address 11 Ralwwai 17 EmpkryaMnt ❑Lost Card
OrlbofE IMPROVEMENT
MPRO EME aB CONTRACTOR WPROYEYELLCONTRACTOR invid 9Hlanody
TYPE:LLC odic,tl Convener dais.Mid awl SuaMum eg
af9�10 0131/110 10P MCa ,-Soft A/170 arltl BlMlnaaRpWdlal
181415 0331/N18 10 PMaPWa•Suib 6170 T4kiEN COLLAR LLC. BetMn,MA 01116
STEVEN ECIOMN \,ECIfn,Y—
STEVENECK ANU r
SOUTH HADLEY.MA 01075 UOMrsecreMry No valid without Signature