29-354 (3) 14 AUSTIN CIR BP-2019-0953
cls#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 29-354 CITY OF NORTHAMPTON
Lot.-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0953
Project# JS-2019-001589
Est.Cost:$5309.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sa. 11): 11979.00 Owner: LEARNED RAYMOND H&BONNIE S
Zoning: Applicant: GREEN COLLAR LLC
AT: 14 AUSTIN CIR
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:3/6/20190:00.00
TO PERFORM THE FOLLOWING WORK I NSUTLATIONMIEATHERIZATION
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 3/6/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
�nl All fl)1 -
Department use only
RECEV ]J413
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability-
[M
vagebility
M:AR:5 Room 100 Water/Well Availability
hampton, MA 01060 Two Sets of Structural Plane
587-1240 Fax 413-587-1272 PloUSite Plans
CFVT oc e ;r, Other Specify
VOPTHAMP'C�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
IO
SECTION 1 -SITE INFORMATN 6 p-IT 'a S.%
1.1 Property Address: This section to be completed by office
�ytASiin Ur Map a� Lot 35V Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
' �pnnle L-earud I NuS-+in C,r N61` ha. ai) Nkl
Name(Print) Cuvent Mailing Atltlrass:
UI >, 5435 k451
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Anent:
Green Collar,LLC 351 Newton St.Unit B.South Hadley, MA 01075
Name �� Current Mailing Address'.
413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5 3o q (a)Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee /
4. Mechanical(HVAC) 6
5, Fire Protection
6. Total=(1 +2+3+4«5) 1 J` 30 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued: p
Signature: zol I
Building Commissionedinspector of Buildings Date
Section 4. ZONING Alt 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 Depi mnem
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Los area minus bldg&paved
pial,ing)
a of 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 Yn enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW eX YES O
IF YE$ 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 Icheok all malleable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors C3
Accessory Bldg. ❑ Demolition ❑ New Signs [0I Decks [0 Siding PI Other[COX
Brief Description of Fra rued
work INgULATIC4N/WEATHERIZATION
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes _ANO
Plans Attached Rall -Sheet
ea. If New 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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. 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 authored by this building permit application.
SEE ATTACHED DOCUMENT
Signature of Owner /n� 9 Daw
ii (� , as OwnerlAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
7Si d under the pains and penalties of perjury.
b �s�tin
XPdnlN e
-N Q" 9 -a� - / 9
Signa[ re of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sunervlsor: Not Applicable ❑
Name of License Holder: CS-108817
Robert Calhoun License Number
8/23/2020
Address Expiration Date
390 Newton St. South Hadley, MA 01075
Signature Telephone
413 532 1817
e.Registered Name Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
351 Newton St Unit B. South Hadley, MA 01075 Telephone 413 532 1817 3/31/2019
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.C.152,§25C(e))
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....... M No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 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 whoconstructs e than 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 shag be
responsible for all such work performed under the buildine 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 rosy be liable 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: Iu INU SHrAG r o
The debris will be transported by: by-fey-, -° (( ur
The debris will be received b1aaK101 i 0- C( nrl( 'r .0
Building permit number:
Name of Permit Applicant -/�
"\C) CG- NU h
212Y) Iq a2—
Date Signature of Permit Applicant
Permit Authorization
mass save Form
Site ID: 3623915 Customer: Bonnie Learned
13&"AuA, Learnzd
owner of the property located at:
(owners Name,prireed)
14 Austin Cir Northampton, MA 01062
(PrcpertyRreel Address) (W
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor Rsted
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
f3ov,v.v, Lea Kt&
Owner's Signature:
1/12/19
Date:
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 di fur Mca Up Only
Rev.102015
The Commonwealth ofMassachuseas
Department oflndustrial Accidents
Office of Investigations
wi 600 Washington Street
Boston, MA 01111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organintion/mdividaap: Green Collar LLC
Address: 351 Newton 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 /2— 4. ❑ I am a general contractor and I
employees(full andlor part-time).w 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 S. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 9. E] Building addition
workers' camp. insurance comp. iasoe3
req corp
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' carl right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.® Othednsidation/Weatherization
comp. insurance required.]
Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
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 suite whether or not those entities have
employees. If the sub-contmaors 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. Lie.#: R2WC855214 Expiration Date:
1 11-9/23/-2L0,19 y1/� —
Job Site Address: 14 Au S�-+n Clr City/State/Zip:I�]AP`�'I�lfA2l 0h II o, (010[02
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 cert y under the pa�innssand penalties of perjury that the information provided above is true and correct
Signature /tom/l"J !/�SY Rr_� Date: 17 'aCp
Phone#: 413 532 1817
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermiULicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Worker's Compensation and Enualever's L(abgity Pepe„
5214
iG
erkshire HathawayAm6UARDInsurance Company-A Stock Co.
Policy Number R2WC998371
Insurance U A R DCOmpanles R.neWaNCCI No.at [218 3]
r
Policy Inrormotlon Page(AR)
[I]Named Insured and Melling Address Agency
GREEN COUAR LLC TIERNEY INSURANCE AGENCY,INC.
351 Newlon St Uret B 16 NORTH ELM ST
South Waley,f1A 01075.2351 Westfield,MA 01085
Agency Code: MATIERI0
Fadaral Employer's ID 47-1041086 Insured Is Limited Liability Co. (LLC)
[2] Policy Period
From September 23,2018 to September 23,2019, 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. Employers Liability Insurance- Part Two of this policy applies to work In Each of the states listed
In Item [3]0. The limits of our liability under Pan Two arc:
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. Rehr to Residual Market Limited 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 Mans. All required Information Is subject to verification and change by
audit. (Continued on another page)
Tool gatini ted Polley Premium ; 10,852
Tool SursNarges/Asaeaments $ 389.00
Total Domow Coe! Si 241.00
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