42-074 (10) 97 GLENDALE RD BP-2019-1090
GIS ft: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:42-074 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cmegorv' INSULATION BUILDING PERMIT
Permit# BP-2019-1090
Protect# JS-2019-001773
Est.Cost, $4952.00
Fee, $656.0 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groum GREEN COLLAR LLC 108817
Lot Size(sa. R.): 4486.68 Owner: ODGERS MARY C&CRAIG W
zo in : Applicant: GREEN COLLAR LLC
AT: 97 GLENDALE RD
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT'B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:4/2/2019 0.00:00
TOPERFORM THE FOLLOWING WORK:INSULATIOWWEATHERIZATION
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: Qk 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 Sienature:
FeeTvoe: Date Paid: Amount:
Building 4/2/2019 0:00:00 $656.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
RECEIVED Building Department Curb Cur/DBverray Permit
212 Main Street Sewer/Septic Availability
APR 2 2019 Room 100 Water(Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
ph], e4pho a 41 -587-1240 Fax 413-587-1272 Plottsite Plans
DEVT or Bull omc ImsPecrloNS Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION 3P" z'?—e 1?69
This section to be completed by office
1.1 Proaenv Address: /� C�
Map�" Lot �77 Unit
Zona Overlay District
f)-rOr) mVO(oL
Else St.Dbldd CB Metricl
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MIar�1 Odgers
Name(Pont) Current Mailing Address'.
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Anent:
Green Collar, LLC 351 Newton St.Unit B.South Hadley,MA 01075
Name(Pont) 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 -1y '/�1 5Z (a)Building Permit Fee
2. Electrical I (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 52- Check Number
This Section For Official Use Only
Date
Building Permit Nu er Issued'
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4qFmot All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Acquired by Zoning
this culumn to be filled in by
Building Department
Lot Size
Frontage
SetbacksL: R:.. L> R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
proking)
N of Parking Spaces
Fill:
volume&Lacatiun
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 p.
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(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? VES 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 Wintlows Alterations) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Deeks j(] Siding Iol Other 15a1X
Brief Descrie2tion of Pro used
Work: INJULATIC�N/W EATH ERIZATION
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
Set.tf 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
a. 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
i. Is construction within 100 ft.of wetlands? Yes _No. Is construction within 100 yr. Floodplain_Yes No
I. Depth of basement or cellar floor belowfinished 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 r Date
1. ��
9(Q.o rl 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.
�n PLa�1Q�Y�
Print Name
Signature of OwnerlAgent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun
8/23/2020
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signature Telephone
413 532 1817
9.Reobterad Home In mnamma ll 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.G.L.c.152,§251
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provitle this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... DO No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does ret 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 fazm
structures.A person whoconstructs re than one 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 Oficial,that he/she shall be
responsible for all such work performed d the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion oflhe work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability ofEmployers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may 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 byMGLc 111, S 150A.
Address of the work: q3 (I to P, `tom
The debris will be transported by: ('i r s ) w 0cur
The debris will be received by: 24 , 1 (' , . 1 t P S
Building permit number:
Name of Permit Applicant 010 cati"o)dl
1�—
Date Signature of Permit Applicant
DocuSign Envelope ID:5291B71B-107F-0941-97FA-1CDFBOD66613
Aft Permit Authorization
mass Save Form
ae.my.tbwy em.nh aNnarv.i
Site ID: 3668128 Customer: MARY ODGERS
MARY ODGERS ,owner of the property located at:
(owner.N-ae,prlwed)
97 Glendale Rd Northampton, MA 01062
(Fnlpwty street Address) (rlty)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherizatlon
work on my property.
Owner'sSiplatu Kl{ DQ6EKS
WB]ACFei4all�..
Dom: 3/4/2019 112:30 PM EST
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
C-)U-QnW1Our 3/�A /fl I
Participating Contractor Date
Name: CLEAResult
Phone: 800-4B0-7472
Email:
Page 1 of 1 for oN¢e Use only
Rev.102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of7nvestigations
WJ 600 Washington Street
Boston, MA 02177
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organimtion/Individual): Green Collar, LLC
Address: 351 Newlon 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):
I.® I am a employer with I L 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.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12 ❑Roof repairs
insurance required.]t c. 152, §l(4),and we have no
employees. [No workers' 13.0 Otherinsulation/Weatherization
comp. insurance required.]
'My applicant that checks box#1 most also fill out(be section below showing their workerscompensation policy information.
`Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new amdevit indicating such.
IConhacmrs that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-comracmrs 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.#: R2WC 165rr52p14-1 Expiration Date: 9/23/2019
Job Site Address: vl� ��Q�t\(r,Q.`c L'�t City/State/Zip:��[y IY10 tmkoL
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 thepainss and penalties of perjury that the information provided above is true and correct.
Signature: Datc� ?3/`q /ICI
Phone#: 413 532 1817
Oficial 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#:
Workees Compensation and Ern-lover's IJablllty Poll
Berkshire Hathawa AmGUARD Ineurance Company-ASock Co.
y Policy Number R2WC9BBS71
Insurance GUARD Companies RenawaNCCI No.l of [21873]
Policy Information Page(AR)
[3]Narned Insured and Melling Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit a 16 NORTH ELM ST
SouU HMey,MA 01075.2351 Westfield, MA 01065
Agency Code: MATIER30
Federal Employer's ID 47.1041066 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- PSR One of this policy applles 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 liablllty 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-WC2003068
D. This policy includes mese endorsements and schedules:
Sea Extension of Information Page-Schedule of Forms
[4] Pranlurn
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)
Tote[Unmated"ICY Premium s 10,852
Tetal Wrcharga/Assessments S 389.00
TOpI-untested Cost 11 241.00
wrawr use ss Page.1- Information Pepr
WA :R2WC9 11 WC 000001A
Ore :8N0412015
M1"rDre
goal"0111101"P,O,11141111 A-H,11 S.Rinr Straep Wilkes-Nne,PA 18703.0020 0 www.guerd,cam
.�ize ��m✓racivaea��a���i`�11�rc��lefG1
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Registration: 181415
351 NEWTON ST UNIT B Expiration: 03/31/2021
SOUTH HADLEY,MA 01075
update Address and Return Card.
SCA1 O �17
.7XI n...vne.n.///.�.//,n.�,+.ir/..�.✓Gi
f„hoe of Consumer ARelrs 6 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC before the expiration date. H found return to:
Reg4litation E=kldo OfMos of Conspmer Affairs and Business Regulation
1814'15- 03/3111021 1000 Washington Street-Suite 710
GREEN COLLAR I.I.C. Boston,MA 02118
STEVEN ECKMAN
351 NEWTON ST UNITS
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature
e ConsnonwasSh of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-108817 Expires: 08/23/2020
ROBERTCALNOUN A,F
800 NEWTON STREET
SOUTH 11AOLEY MA 01176
e
Commissioner 1�