29-086 (9) 410 RYAN RD BP-2018-1196
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:29-086 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-2018-1196
Proiect# JS-2018-002143
Est.Cost:$2848.00
Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sn. ft.): 12501.72 Owner: KRAUSE GREGORY I&KAREN L
zoning: Applicant.- GREEN COLLAR LLC
AT. 410 RYAN RD
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.5116/2018 0:00:00
TO PERFORM THE FOLLOWING WORKADD 13" CELLULOSE TO 960 SO FT ATTIC
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 5/16/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
of Jorthampton .cTt�eml7k , ''
IF
Department
UY � ; 281ain Street
m 100
- on, MA 01060
RAA !-1 0 Fax 413-587-1272wcw
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISHHA ONE OR TWO F/A%y,MILY DWELLING
SECTION I-SITE INFORMATION V' V l p 11 "
1.1 Property Address: This section to be`'�P by OMM
�`
Map �t.q La / 1 0 urnt
Zone Overlay District
Elm SL District CB Dlebict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6 --faofid lifrow 4-2 Yle
Name(Pdo C. tMallin dress JO2
St- 14?rC lEDTelephone S8�—
Signature
2.2 Authorized Agent:
Green Collar,LLC 3 Main St. Unit B.South Hadley,MA 01075
Name(Pont) Current Mailing Address:
413 532 1817
SignAtA TelepM.
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermitapplicant
1. Building �(.�P (a)Building Permit Fee
2. Electrical 0 (b)Estimated Total Cost Of
Construction from 6
3. Plumbing Building Permit Fee /�CC
4. Mechanical(HVAC) (J(u
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number o2
This Section For Official Use Only
Building Permit Number' Date
Issued:
Signal e:
Building missionerllnspector of Buildings Data
ZFmnw
n 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
e
Setbacks Front
Side L: R'._. L: R
Rear
Building Height
Bldg. Square Footage
Open Space Footage ---
(Loi area minus bldg&paved — -
parking)
#of Parkin Spaces
Fill: .__. ...
vnwmc&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 g)X 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: I.
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,goading,/�excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 1" X
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(chock all applicablel
New House ❑ Addition ❑ Replacement Windows Alteralion(s) 0 Roofing ❑
Or Doors 0
Accessory ppBldg, ❑yy Demolition ❑ New Signs [ol Decks [p Siding 0:3] Otyherr[[®]X
Brief Work eINbIULATIUN%WEATHERIZATION i!r!A Z y6`l4,ldX �s f419 814144 c4S
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement _Yes __—�L_No
Plans Attached Rall -Sheet
er if New house and or addition to exiding housing complete the followings
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
1. 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=
OMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR
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 auNorizetl by this building permit application.
SEE ATTACHED DOCUMENT
Signature of Owner L Date
elov
I e5c ^ .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
Si of OZ.- 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 Data
390 Newton St. South Hadley,MA 01075
Signature n Telephone
2 l , 413 532 1817
9.RLa4wW Home IntDreVIneW Contractor, - Not Applicable ❑
Comoan f Name Registration Number
Green Collar,LLC 181415
Address Expiration Dale
3 Main St. Unit B. South Hadley, MA 01075 Telephone 413 532 1817 3/31/2019
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ni 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...... ❑
11.-Home Owner Eaem don
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 for hue 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,oris intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person h constructs more than one home ovor-year period shallot 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 bulletin,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 Armotatcd,You may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner'cerdffes 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: e'/b &a/, /z
The debris will be transported by: V/4 /Ub 0-A6J-
The debris will be received by: � Ztld a-,61-)TL
Building permit number:
Name of Permit Applicant
�/F//S
Date Signature of Permit Applicant
Columbia Gas
Of MaSSaChUSeM 60 Shawmut Road, Unit 2 Canton, MA 02021
an0.4emn Comp,ry
OWNER AUTHORIZATION FORM
I, Gregory Krause
(Owner's Name)
owner of the property located at:
410 Ryan Road
(street)
Florence, MA 01062
(Town, State, Zip) /" /
hereby authorize t�r ,� (y� l.( p,�-- -. .
-
(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.
Pustomerj nature
�_l_- > -� _
-Sign Date
4/2012018
The Commonwealth ol"Massaehusetts
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/OrganizatioMndividuap: 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.® I and a employer with 6 4. ❑ I am a general contractor and I fi. E] 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.:
required.] 5. ❑ We are a corporation and its ]0.❑ 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.[K Othednsulation/Weatherization
comp. insurance required.]
Any applicant that checks box kl must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire onside commons 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 sate whether in not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comppolicy 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. Lic. r#: R2nWC855214 Expiration Date: 9/23/2018
h1
Job Site Address: ' (0 City/State/Zip: 7 Ce zo
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 under thepains and penalties of perjury that the infornaaBan provided above is true and correct.
S' amr�� Date'
Phone#: 413 532 1817
Official use only. Do not write in this area, to be completed by city or town ojjieiat
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 Compronsetlon and Emoleydes LlabRNv Policy
of NEW
AUARDiCompanles
rkshire Hathaway Am6UARD Insurance Company-AStock Co.
y Policy Number RM855214
Insurance NCCII No 1[21873
Policy Information Page(AR) `
[I]Named Insured 440 Mailing Address Agency
31MOV STRIET UNIT.a 6ENORTH ELM ST AGENCY, INC.
SOUTH HADLEY,MA 01075 Westfield,MA 01085
Agency rode: MATIERIO
Federal Employer's ID 47-1041086 Insured is LanKed Lebli ty Co. (LLC)
[2] Policy Period
From September 23,2017 to September 23,2018,12:.01 AM,standard time at the Insumd'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. Employees Uebl ity Insurance-Part Two of this policy applies to work in each of the states listed
in Itam[3]A. The limits of Our liability under Part Two are:
Bodily Injury by Accident-each accident $5001000
Bodily Injury by Disease-each employee $500,000
Bodily Injury by Disease-policy Iknit $500,000
C, Refer to Residual Market Limited Other States Insurance Endorsemem-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 Pians. All required Information Is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 13,325
Total Surcharges/Assassments $ 584.00
Total Estimated Cost 13 909.00
ItlMM&USE_g1 Page- t - Inrom arks,Page
tua :R2WMN14 WCOOOOOIA
Date :10f0212017
MANOTE
Issuing Office:P.O.Box A-M, 16 S.River Street Wilkes-Urm,PA 18703-0020•www.guard,com
Massachusetts Department of Puaoc Safet'v.
Board of Building Regulations and Stands
License.CS-108817
ROUM CALHOUN
780 NEWTON ST
SOMH HAOLEY MA 01079
r j= LA—
Commissioner OWI&2m0
C��ie eCarnnea7rcavtzlt� a�C��ccc�tuuteC�.a
ri
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Typr LLC
GREEN COLLAR LLC. 181415
3 MAN ST.UNIT B. Expiration: 031311201e
SOUTH HADLEY,MA 01075
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181115 0391/2019 10 Pan Plara•Bups 0170
"GREEN COLLAR U.C. Goes^MA 07119
STEVEN ECKMAN
3MAIN ST.UNIT B.
Not valid
SOUTH HADLEY.— 01915 Undervalarstary
validwi6fout slgneturo
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