38A-001 (4) v
38 BURTS PIT RD BP-2020-0509
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38A-001 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-2020-0509
Proiect# JS-2020-000866
Est.Cost: $3456.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 10018.80 Owner: EXFORD DORRIN
Zoning: URB(I00)/RR(0)/ Applicant. GREEN COLLAR LLC
AT. 38 BURTS PIT RD
Applicant Address: Phone: Insurance:
390 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.1012312019 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE CRAWL SPACE
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 Deaartment 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 SiVnature:
FeeTyae: Date Paid: Amount:
Building 10/23/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-11272
Louis Hasbrouck—Building Commissioner
b�' -0�o
Dep
City of Northampton al?
w Building Department
i L 212 Main Street INSULATION
Room 100
Northampton, MA 01060
W phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address: This section to be completed by office
3 p `S ��+ �d Map_ _A 'y (
_ Lot W 1 Unit
0 Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(\ �xfo(-8 d
Name(Print) Current Mailing Address:
13 r7�� — ( D(O
e C (x-t+C��l�-P CA Telephone
Signature
2.2 Authorized Agent:
�ob lho�n 3S ( N�wtc,� S-t . Sc,�th IPTAO
Name(Prin Current Mailing Address:
Sig ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building , /��� (a) Building Permit Fee
2. Electrical �1 (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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: Z�` JQ' ZZ -ZQIq
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
590 �ew�oln S � Sou+h 1-�acllc.�;�� oto-15 c6 J 2 3 1 W 2-b
A ss Expiration Date
Lill -532 -41 -7
fi 1 -7
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Grecn 191915'
Company Name Registration Number
351 t4y\jkoy\ S+. 3A3i I2b2i
Address ' Expiration D to
Jtbxe- `RCI( cs ,A(L 01 1 5 Telephoneq13
SECTION 5-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 building permit.
Signed Affidavit Attached Yes....... No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
�lC)y 9 d ermaX jnSwlor" on -to yy0q} 1-o Cro���srx�cP
\orc\\ ?0\1 -�D 352 S,&-t --j-a Cr`awlspc��
I 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
Signature of Owner/Agent Date
, as Owner of the subject
property �+
hereby authorize Grp e n l O`� a(— , LLC
to act on my half, in a matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJ�. meati
Northampton, MA 01060
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 owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be rlg11 eistered.
Type of Work: �l�o. Y�?�'�'� an Est. Cost— S , `1 `J— LP
Address of Work: ?I + "Qd
Date of Permit Application:
I 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 PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
10 -I(.91 1 G C-1rge Co
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts ��
c
( L,,A
DEPARTMENT OF BUILDING INSPECTIONS H
` 212 Main Street •Municipal Building
N Northampton, MA 01060 sbW �7�1
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:
7) 9 "'1ur+i S ? k `Q d
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
re co (kr 1Ll I i S+ Sovr+h, �ad�e'
(Company Name and Address)
S gnat e 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.
City of Northampton
' Massachusetts `
v � �
s.
DEPARTMENT OF BUILDING INSPECTIONS S;
212 Main Street • Municipal Building v4J,
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 7,7) ��.1-�1� S 914 Pol
Contractor
Name: GV'f.-f n o Mkt"r
Address: �� ` U e\tj �—U' C"i
City, State: �(�v,+h �ACK6\-eel
Phone: LW - 53 2-- �k� --I
Property Owner
Name: �orri n
Address: 11fr�
City, State: p10.YY1�'J
I, G W n l �A <' (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
RISE
ENGINEERING-
OWNER AUTHORIZATION FORM
I, Dorrin Exford
(Owner's Name)
owner of the property located at:
38 Burts Pit Road
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize -)rf t I L
(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.
Owner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 02021 1 339-502-6335
www.RISEengineering.com
cp4� L"V of fir.uJ qua,/LUJGaw
aiMrtr� 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 Legibly
Name(Business/Organization/Individual): Green Collar,LLC
Address: 351 Newton St. Unit B
City/State/Zip: South Hadley,MA 01075 Phone M 413 532 1817
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 11 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
workingfor me in an capacity. employees and have workers'
Y P tY• 9. ❑Building addition
[No workers' comp.insurance comp.irisurance.t
required.] 5. ❑ We are a corporation and its 10.E]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' 131M Otherinsulation/Weatherization
comp.insurance required.]
*Any applicant that checks box#I 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 outside contractors must submit a new affidavit indicating such.
TContractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
AmGUARD Insurance Company - A Stock Co.
Insurance Company Name:_
Policy#or Self-ins.Lic.M R2WC053509 Expiration Date: 9/23/2020
111
Job Site Address: �0 U ,City/State/Zip: 1V��ampk iMa
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 the pains and penalties of perjury that the information provided above is true and correct
Signature CDate:
Phone M 413 532 1817
Official use only. Do not write in this area,to be completed by city or town ofciaL
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#: