17A-271 (6) 126 OAK ST BP-2019-1108
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-271 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-2019-1108
Proieet# JS-2019-001797
Est. Cost $6867.00
Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq ft.): 10018 80 Owner: OLANDER DEBORAH LIVINGSTONE
Zoning: URB(100)/ Applicant. GREEN COLLAR LLC
AT. 126 OAKS
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:4/5/20790.00:00
TO PERFORM THE FOLLOWING WORK.-DENSE PACK CELLULOSE, OPEN BLOW
CELLULOSE IN 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 Occuoancv Signature:
FeeTvoe: Date Paid: Amount:
Building 4/5/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
e P jq-cog
1 - iVEL DefOR
City of Northampton — -
Building ep treetA � �/�
212 Ma n StreetAPR 5 2019
` Roo 100
Northampt , MA-&1 _ /t�
phone 413-587-124 Fax 413-587-102 s ONLY NL
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY �// -
SECTIONI -SITE INFORMATION INSULATION PERMIT
1.1 Prooertv Atltlress: This section to be completed by office
I2-(9 OaV,; Map Lot a�l Unit
-
Zone F lorenc
Zone Ovaday DietrkY
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
I0e121011 (Dlav)Ck,� 12 up f)ziv, .3A ,fInr(rice , ^41 OIOtaL
Name(Print) Current Mailing Address'.
�,, .y13 - E;AH- 3glq
S -4 0-44 r,Vq&f (,LOCI n-iX Telephone
Signature
2.2 Authorized Anent:
GLrxen Co116Lr _LLC 351 JJPurbn�# UntB , Sr�hH yl o�
Name(Print) Current Mailing Address:
Imo' gl;- 532-ILII
gr�gnature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit a licam
1. Building W O W l (a)Building Permit Fee
2. Electrical 0 1 (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee /D
4. Mechanical(HVAC)
5. Fire Protection ('
6. Total=(1 +2+3+q+5) I a(p Check Number a
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature: / y-5-2019
Building Commissionecinspeclor of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4•CONSTRUCTION SERVICES
61 Licensed Construction Supervi�slor: Not Applicable L1p
Name of I-Ii Holder: ROUPY-4 \(� aL1-1DUh �s - Iv �ol�
License Number
351 "COIN 14 'K •z3- U-bo
Address Expiration Date
91r 1 11
Sgna� Telephoneone
B Registered NIrrrorovamantC ntragi Not Applicable ❑
�1r �oIlay rtl IBI415
CompanyyNameName Registration Number
35� Nt"JlorS� Uni}ice Sou-Vir\6 UJ7 M Duo a ai z.Dz�
Address — Expiration Date
Telephone41 5-S�1"Ik11
SECTION S.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,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 buildin permit.
Signed Affidavit Attached Yes....... No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Dek,s2 PGUC C-eN)vse ; 0 >en NOW r
as Owner/Authorized
Agent hereby aeciare mat the statements and information on mt oregoog application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
I, Jr f 1a. +�a(,Y FCA C5 M I-me 1A ,as Owner of the subject
property ]]n� � /�
hereby authorize Vrer[I Cobs LLC
to act on my behalf,in all matters relative to work authorized by this building permit application.
See akftcVtPd CIWUMe11±
Signature of Owner Date
City of Northampton
s qI
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS i
212 Main Street • Nunicipal Buildlnq C�
NorNempeon, NA e2060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing
at least one but not mare than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: !A&I_ka_-,4 Qr', G _ Est. Cost:_
Address of Work: `2�p \1lA/h Si
r—
Date of Permit Application: 3 / CI
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
413 / Iq C�(��nfnlla.r LLL 1 $ 14IS
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
<� uaes
` DEPARTMENT OF BUILDING INSPECTIONS 2 ��
\ 212 Hain Street -Municipal Building
Northampton, HA 01060 y0P°
Debris 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.
The debris from construction work being performed at:
Ito WA S�
(Please print house number and street name)
Is to be disposed of at:
a�po�Mli(, fin tm ea Ck1i(�QCj
lease print name a�cation of fac ity)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
4 I 3 /Irl
ature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Permit Authorization
mass save Form
Site ID: 3759225 Customer: DEBORAH OLANDER
Deborah Olander , owner of the property located at:
(Ownefs Name,primed(
126 Oak St Northampton, MA 01062
(propeM Stree Mtress) (cMl
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 weatherization
work on my property.
^
Owner's Signature: CI Le...
Date: 3/16/19
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
C3r.veo Collar LLL q / 3119
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Pere 1 d 1 For office Use Only
Rev,102015
The Commonwealth of Massachusetts
Department of Industrial 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 Leeibly
Name (Business/organizaeowlndividuap: 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):
1.® I am a employer with I L 4. ❑ I am a general contractor and I 6 E] New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I a t 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 11.F] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] it e. 152, §1(4), and we have no
employees. [No workers' 13.® Othednsulation/Weatherization
comp. insurance required.]
`Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new amdas it indicating such.
=Contractors that check this box must attached an additional sheet showing the mine of the sub-contractors and state whether or not those entidcs have
employees. Ifthe sub-contractors have employees,they must gnvide 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: 9/23/2019
Job Site Address: I7UP I)rL,IL SA City/State/Zip:Fl0YP17(fl ALR C,ID(oL
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 e. 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 the pains and penalties of perjury that the information provided above is true and correct
Sumatur : .L I/ aw P��� Data
Phone#: 413 532 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 Compensation and limishwer's Liability PoIIVL
erkshire Hathawa AmGUARD Insurance Company-Aetock Co.
Y Policy Number R2WC988571
55214
kqG1
UARDCOmpanles RenewalNCCI Na[21873]
r
Policy Information Pape(AR)
[3]Named Insured and Melling Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St unit B 16 NORTH ELM ST
South Nadi MA 01075.2351 Westfield, MA 01085
Agency Code: MATIERIO
Federal 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.
131 Coverage
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'CDmperuaNan
Low 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[31A. The limits of our liability under Pan 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-WC200306B
D. This policy Includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
(4] Pray lum
The Premium Basis and,therefore,the premium will be determined by our Manual of Ruin,
Classifications,Rates,and Rating Mans. All required Infomation Is subject to verification and change by
audit. (Continued on another page)
Tow PaUma- Policy Premium ; 10,852
Tow gun*argm/As mints ; 389.00
Tspl mated Cost 11241.00
Pape- I- Information Pepe
a" :a2wc+ea» WC 000001A
as :pyoy2ou
"AWN
trade;offou P.O.aex A-M,se a.slue,Sunt,wnkwurrs,PA 18703-0020 9 www.puerd.ram
.�e (inrrarn�2ct�a,�>�1���//1U�3.1�rc�c-le�f1
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLQ Registration: 181415
351 NEWTON ST UNITE Expiration: 03/31/2021
SOUTH HADLEY,MA 01075
Update Address and Return Card.
SCA1 O 20MO17
Oaks M Cmrsumer Aealre 6 Bu.m.Regullalen
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
RegWration EEBIraOgO OMcs of Consumer Affairs and Business Regulation
181415 031311202/ 1000 Washington Street•Suite 710
GREEN COLLAR U.C. Boston,MA 03118
STEVEN ECKMAN
351 NEWTON ST UNIT e
SOUTH HADLEY,MA 01075 UMenaoretary Not valid Without signature
CORenonwsaith or Massuhumns
Division or Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CSA08817 EBpires:08/23/2020
ROBERT CALHOUI '
3G0 NEWrON STREET
SOUTH HAaEtVI/M' LBOMGa�
e
Commissioner