25C-098 (5) 63 GRANT AVE BP-2019-0183
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:25C-098 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-2019-0183
Project JS-2019-000306
Est. Cost: $2232.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sp.ft.): 8886.24 OWner. EDMUNDS ROBERT L&GEORGIA P
Zoning: URB(100)/ Applicant: GREEN COLLAR LLC
AT. 63 GRANT AVE
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.8/15120180:00:00
TO PERFORM THE FOLLOWING WORKADD 8" CELLULOSE TO 712 SQ FT ADDITION
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:
FeeType: Date Paid: Amount:
Building 8/15/2018 0:00:00 $65.00
212 Main Sneer,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
n —
Depatunent use only
City of Northa sta "of pemdb
B�iWinn Dep t Curb CuKWvft yPemdt
z42 X s
AUG r' SeviedSeptic AvaiWm ity
Room 1 0 Weal AvailaWky
Eiccnic.Pi„ ..��..A,01 60 Twd Sale of Structural Plans—
pho,
'"' ' 41 -587-1272 plousite Plans
Other Sp®clfy
APPLICATION TO CONSTRUCT,ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONi -SITE INFORMATION gp_ q-(Y3
1.1 Property Address: QT'+his section to be eomple'9d by office
3- Mapes Lot Q '1pUnit
f Zone Overlay District
-
Else St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
scArtiw'�s /,7
Name(P� Curent Maim,Addre
Telephoner
Signature
2.2 Authorized Anent:
Green Collar,LLC 3 Main St.Unit B.South Hadley, MA 01075
Name(Print) Current Mailing oddress:
413 532 1817
Sig Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bv permita licant
1. Building // // (a)Building Permit Fee
2. Electrical /[ aC (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
Date
Building Permit Number: Issued'
Signa e:
Building Comm, IlnspectoT of Buildings Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thi,column to bo filled In by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:.. R: L: R:
Rcar
Building Height
Bldg. Square Footage
Open Space Footage % -
(Lot aou minus bldg&paved
.kin
4 ofParking Spaces
Fill
volomc&Lucadnn
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T 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 YFS enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW g1X 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 pad 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 applicablel
New House ❑ Addition ❑ Replacement WindowsAlteration(s) ❑ Roofing E]Or Doom D
Accessory Bldg. ❑ Demolition ❑ New Signs [i Decks [M Siding[i Other[MX
Brief. IN tion of Pro osetl �/ a ,( ?Act/pre / Z�Z ,r� n'A
Work. INpSULATICYN/WEATHERIZATION f11f'I 3 ro CY ffY'T,.-
z
Alteration of ensting bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes XNo
Plans Attached Roll -Sheet
Bir.If Now house and or addition to existing housing, complete 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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or W oodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
If. 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 mailers relative to work authorized by this building permit application.
SEE ATTACHED DOCUMENT
Signature of Owneerrq Data
I, as Owner/Authorized
Agent hereb clare 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.
,51e,�e F✓�,n ate.
Print Name
Sig [u2 of Owner/Agent Dale
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, MIA 01075
Signal Telephone
413 532 1817
9.Realatered Name Imnmandam nt Contractor: Net 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. 152,5 25C(S))
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__... X 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 for 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 residcs 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 whoconstructs than one home in a t 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 Supervise r your presence on thejob 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 perfmrn work for you under this permit.
The undersigned"homeowner"cenifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and Stale of Massachusetts General Laws Annotated.
Homeowner Signature
Owner Authorization Form
Geor9i0. Edm.wn.ds -
(Owner's Nome)
Owner of the property located at:
r3 G �ah � Stmt -
(Property Address)
(PiopenyAddress)
hereby authorize Green Collar .a certified Mass Save Nome Performance
Contractor,to act on my behalf to obtain a building permit and to perform
work on my property,
Or
(owner's Stgnature)
*2LZb-w)iA
(Dare)
Scanned with CamScanner
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: 10lf7 e5��t'+ �Y
The debris will be transported by: .1, tel /LoQid1��
The debris will be received by: i+,� /l/lo ��.6 (,-
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
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(Hosiness/Orgauizationnudividn 1): 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 am a employer with (9 4. ❑ I am a general contractor and[ h El 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' q ❑ Building addition
[No workers' comp. insurance comp. insurance.#
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 l l.❑ 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#1 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.
=Conovelors 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, Tribe sub-omaracmrs have employees,they most provide their workers'comppolicy 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.
�Liic.#: R2W/C855221144 Expiration Date: 9/23/2018
Job Site Address: l0 7 �TJY^-7 / 1: 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 under thepains and penalties of perjury that the information provided above is true and correct.
Sumature Date'
I
Phone#: 4]3 532 1817
Official use only. Do not write in this area,to be completed by city or town of rcial
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 13ablllty Policy
erkshire Hathaway AmGUARD Insurance Company-A Stock Co.
Y Policy Number R2WC855214
Insurance or NEW
k1G,
UARDCompanies NCRaN•/[21873]
Policy Information Page(AR) �Z
[I]Named Insured.and Mailing Address Agency t>JUl
GREEN COLLAR 1lt TIERNEY INSURANCE AGENCY,INC.
9 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 UabllRy Co. (LLC)
------------
[2] Polity Period
From September 23,2017 to September 23,2016,12:01 AM,standard time at the insured'.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 accident $500,000
Bodily Injury by Disease-each employee $500,000
Bodily Injury by Disease- policy limit $500,000
C. Refer to Residual Market Umited 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 $ 13,325
Total Surcharges/Assessments $ S84.00
Total Estimated Cost 13 909.00
RIA"VSE _O8 Page- 1 - Information Page
MGA :R2WC855214 WC OOOOOIA
oche :10/02/2017
MANOTE
Issuing Office:P.O.Box A-H, 16 S.Rlxer stmt,Wilkes-Barre,PA 187010020 a www.gwrd.com
'dassachusetts Department of Puobc Serial,, '
Board of Building Regulations and Stands
License.CS-108817
.:orsr•vcv
ROBB1tT CALHOUN
390 NEWTON ST
SOUTH HADLEY &/ 01076
(��n VL.— EX,,, .
COmm,ssioner Ot125R010
'�`te �a�n•naa�rcoea�ltc a�C�slccc�ucae�a
Y
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COU-AR LLC. 181415
3 MAN ST.UNIT B. E)Orauun: 03/31/2018
80UTH HADLEY.MA 01075
Update Address antl nWm card. Mark rMaon mr charge,
sc+, o areas„ ❑ Address ❑Rensiaal O Employme d O Lost Card
ry
HOME IMPROVEMENT
CONTRACTOR
ONTRACTOR on
Registration vdltl far Inift,lasuil ro onlyTYPE:LLC hale RloudrNum
L� Elim Omen of Consumer Afthit and Business Reg
Yslb
187415 0191/2019 10 Park PMu•Sulu 8170
J 'GREEN COLLAR LLC, GooWn,MA 02110
STEVEN ECKMAN
8 MAIN ST.UNIT B.
SOUTH HADLEY. 01015 Undersecretary Not
1RYI
MA it without signature