30B-083 (3) 35 LADD AVE BP-2018-1195
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map'Block:30B-083 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perna Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2018-1195
project JS-2018-002141
Est.Cost: $3972.00
Fee, $65 00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sm.ft.): 68824.80 Owner: GLASS LAKE PARTNERS LLC
zonine�SIn25VWPB91/ Applicant: GREEN COLLAR LLC
AT. 35 LADD AVE
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.511612018 0.00:00
TO PERFORM THE FOLLOWING WORKADD 10" CELLULOSE TO 1204 SQ 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 OccuoancV Signature:
FeeTvoe: Date Paid: Amount:
Building 5/16/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,In:(413)587-1272
Louis Hasbrouck—Building Commissioner
l µ
didi
HECEI
C ty of Northampton Stalusof Peg?it ,
B idding Department [anti. 'Pasiaa,,.�„„_i_,.,,,,,,."
MAY 14 2016 212 Main Street BewenBgft n
Room 100 WoowAI esf lllbd�y "
No hampton, MA01060 1°sratobeta of stdal .
DEPT aESMDaIeMW413- 87-1240 Fax 413-587-1272 P"SRe Phil& - '
�. other SPecly
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I-SITE INFORMATION 17 !'r II- t /4�5—
1.1 Prooertr Address: T�hiiss section to be comPI by off"
Map Q SUUU(/j, Unit
r Lcd� R/iC Zone Overlay District
Elm SL District CO Dlatdot
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
aaSI J kz �r�tcrs 44 <-
Name(Print) Current Mailing Morass y
/*� /�' iFCff{� yOLG�/�rp� / 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
Signat Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building � v�7/} (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) u ��
5.Fire Protection
6. Total=(1 +2+3+4+5) Gf �� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued'
Signatur .
Buil ll C ' slonerllnspaclor of Buildings Dale
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 filial in by
Buildln,Dept
Lot Size
Frontage
Setbacks Front
Side L _- R:.
Rear
Building Height --
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Puking Spaces
Fill: ..
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW QX 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 g)X YES O
IF YEB, 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 a 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 OX
IF YES, than a Northampton Ston Water Management Pemlit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Ich"Ir all apOW11,1e)
New House ❑ Addition ❑ Replacement Windows Alterations) E:] Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [O Siding[l3] Other[CMX
Brief Descripption of Praosed �yj�
Work: INJULATI (£
N/WEATHERIZATION N le "Cel&6fp
Altemhon 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 kotue and o7 addition to existing housing,complete the fonowing:
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 stones?
I. Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
It. 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 applicalion.
SEE ATTACHED DOCUMENT
Signature of Owner Date
C!! 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
Signate6 of Omer/Agent 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 one.
390 Newton St. South Hadley,MA 01075
Signature Telephone
P ^ 413 532 1817
9.Resp CaerbndRemehnprovamaMCeilhactor. 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(ill c.152,§25C(8))
Workers Compensation Insurance affidavit must be completed and submitted oath 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. -Rome 4wnee Eaempda
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines fone(1) or two(2)families
and to allow such homeowner to engage an individual for hive who does not possess a license,Provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Defmltion 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 tw ear period shalt 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 d the building mit
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion ofthc 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 Hable 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: 75- Ai -
The debris will be transported by: ,/X114 /a is Xi, S
The debris will be received by: 4q'1'-
Building
qSiBuilding permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
RISEr 60 Shawmut Road, Unit 2 Canton, MA 02021
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Glass Lake Partners LLC
(Owner's Name)
owner of the property located at:
35 Ladd Avenue
(Street)
Florence, MA 01062
(Town, State, Zip)
hereby authorize Gee,,_. l(.[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 municipa14 at the compl n of this work.
1, I
-Customer Signature
l2- _? -- I `(
Sign Date
121712017
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 (Business/Organization/Individual): Green Collar LLC
Address: 3 Main St. Unit B.
City/State/Zip: South Hadle ,MA 01075 Phone #: 413 532 1817
Are you an employer? Check the appropriate box: Type of project(required):
L® I am a employer with_� 4. ❑ 1 am a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
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.t
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 11.❑ 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.® Othednsulation/Weatherization
comp. insurance required.]
'My applicant that cheeks larval must also fill out the section helow showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConirac ors that check this box most attached an addiliorel sheet showing the name of the sub-contracmrs and slate whether or not those entities have
employees. If the sub-contrectors have employees,they must provide their workers'comp.policy number.
lam 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.Lic.#: R2WC855214 Expiration Date: 912312018
Job Site Address:J"S ��� .4 _ City/State/Zip: T_"etl
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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is trueandcorrect.
fah re Date- o
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 Comoensation and Employer's Lleblllty Policy
Berkshire Hathaway Am6UARD Insurance Company-A Stock Co.
Y Policy Number R2WC855214
Insurance of NEW
JOG,UARD Companles NCCI RonN. [21873]
PolicyPolicy Information Page(AR)
[1]Named Insured and.Mailing Address Agency
GRVM COLLAR LIC TIERNEY INSURANCE AGENCY, INC.
3MAIN STREET UNIT B 16 NORTH ELM ST
SOUTH HADLEY,MA 01075 Westfield, MA 01085
Agency Code: MATIERIO
Federal Employer's ID 47-1041086 Insured is LknRed Liability Co. (LLC)
(2] Policy Period
From September 23,2017 to September 23,2018,12;01 AM,standard time at IN Irlsured's mailing
address.
[3] Coverage
A. Workers'Compensation Laurence- Part are of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
S. Employers Liability Insurance-Part Two of this policy applies to work in each of the states listed
in(tam[3]A The Omits 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-WC2003065
D. This policy Includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
[4] Premium
The Premium galls 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/Assessments $ 584.00
Total Estimated Cost 13,909.00
g 10111AL M—Q1l Page- 1 - INonnation page
MGA :FUWW55214 WC 000001A
Mo :10102/2017
MANM
Issuing office:P.O.Box A-N, 16 S.River StnN,111111,61-Barre,PA 18703-0020•www.9uard.cmn
.".laasaWhus efts Department of POohc Safer;.
Board of Building Regulations and Standaudsm
License. CS-100817
ROBERT OALIIDIM
ew tEWrON ST
SOUTH HADLEY MA 01.070
Exp,
Commissions eflEUY010
L%6ee arn�>eanueall�i albl&u/a�
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
TYPE U.A
GREEN COLLAR LLC. RepeOatlal: 18/415
3 MAN ST.UNIT B. ExWrabom 09/31/2019
SOUTH HADLEY,MA 01075
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