17B-009 (2) 428 BRIDGE RD BP-2020-0514
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-009 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-2020-0514
Proiect# JS-2020-000886
Est.Cost: $5477.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sa.ft.): 29010.96 Owner: QUINLAN THOMAS
Zoning: RI(100)/RR(100)/ Applicant. GREEN COLLAR LLC
AT. 428 BRIDGE RD
Applicant Address: Phone: Insurance:
390 NEWTON ST (413)532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:10/23/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION TO 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 Occupancy Signature: ,
FeeTvpe: Date Paid: Amount:
Building 10/23/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
off'"— - City of Northam ton CDep
.� Building Depart ent
. 212 Main St et OCT SULATION
Room 1
Northampton, A Cb_
phone 413-587-1240 FA �f��
glanr (IIN's ONLY
Ok',1A EC O
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY D ONLY g �� r Jif
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address: This se tion to be completed by ffice
9 -2 Map � Lot _Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1 nota
QIAJ6
Name(Print) Current Mailing Address:
ul 3 - 3()y
Telephone
Signature
2.2 Authorized A ent: ff `` L
,reLt1 �a lCc r^ 351 IVeV- - c A J UnI I
Name(Priest) Current Mailing Address:
Y13 -- 9)1
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building F— (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee _r
4. Mechanical (HVAC) GJ,
5. Fire Protection
6. Total = 0 + 2+ 3+4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature: -
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:r�; h Not Applicable ❑
1 -7
Name of License Holder s K1 I QA�/1 1 CS ' lb8(�
W�-1
License Number
tjCk a167s � 1231 -L62-0
Address Expiration Date
Signature,�v Telephone
9.Reallstered Home Imarovement Contractor: Not Applicable ❑
Oren WLC , LLC 1( Sl9 1�
Company Name Registration Number
Add r Expiration Date
}f ()
UVW'V 1 � tK I Q V``�7� Telephone U�3-53)-(81 �
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.......I No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
iCiS�w )a �l ce,��(,Lkow I-a ) 360 SbI
Cie--een ('o��c' r
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.
c,b coahQx
Print Name
/ 0 . ( S ./g
Signature of Owner/Agen Date
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
Massachusetts
DEPARTANNT OF BUILDING INSPECTIONS �y
212 Main street • Municipal Building
Northampton, MA 01060 4 ""
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 registered
Type of Work: Est. Cost:
Address of Work:
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 -f� 1 /9 C1r<ert (c, l( --�— IK I`1
I I
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
�• DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
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:
92
I 0Sdu
(Please print house r#jmber and street name)
Is to be disposed of at:
�r�en Gl lar 1
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
-S 06"�A /�ad(tfj
(Company Name and Address)
01V
Signa r ermit 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
e
� N
" DEPARTMENT OF BUILDING INSPECTIONS �Nf
212 Main Street • Municipal Building yJh�Sb �1�CD`
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: L42 �C&
Contractor Grc<r� ol Lott-
Name: J,,,,,//
Address: 5I (�I Vl �7 V(x,(��� /w `�--e"-/ "a
City, State: )) 1 ) Q
Phone:
Property Owner
Name.-
Address:
ame:Address: oed
City, State: MW
I, ( o, f-f' a CO l �c-t--- (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.
i
Contractor signature
Date
DocuSign Envelope ID:8D67D694-51 B7-470D-B29D-D49F32E4F2C4
Permit Authorization
mass save Form
Site ID: 3894707 Customer: THOMAS QUINLAN JR
l� Thomas F Quinlan JR , owner of the property located at:
(Owner's Name,printed)
428 Bridge Rd Florence, MA 01062
(Property Street Address) (City)
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.
uSigned by:
Owner's SignatureFT�KIOLS F alAI un,
EA95DF50B127428...
Date: 10/3/2019 18:34 AM EDT
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
C,Cfe V1 �C) D
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Mte Use Crly
L/6G %,UM"tuft WCULL/L Vf /rl uJJul./LUJGLLJ
d� 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 Ledbly
Name(Business/Organization/Individual): 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 12 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 H. ❑ Demolition
working for me in any capacity. employees and have workers' q ❑ Building addition
[No workers' comp.insurance comp.insurance.t
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' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Othetinsulation/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 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 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 is providing workers'compensation insurance for my employees. Below is the policy and job.site
information.
AmGUARD Insurance Company -A Stock Co.
Insurance Company Name:_
Policy#or Self-ins..L'ic.#: R2WC053509 Expiration Vate: 9/23/2020
Job Site Address: 2g �nC�QIe d City/State/Zip: Nonbamaw tA� 6�6�0 2
Attach a copy of the workerscompensation 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 ce nder the pains nd penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone M 413 532 1817 00 X i
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#:
A Worker's Compensation and Emglover's Liability Policy
�// AmGUARD Insurance Company - A Stock Co.
Berkshire Hathaway Policy Number R2WC053509
t `' GUARDiCompanies Renew l of 8571
Insurance
NCCI No. [21873]
,twoPolicy Information Page (AR)
- --.........._
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit B PO Box 750
South Hadley, MA 01075-2351 Westfield, MA 01065
Agency Code: MATIER10
Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC)
Risk ID Number 1038965
I
[2] Policy Period
From September 23, 2019 to September 23, 2020, 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. 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
i
Bodily Injury by Disease - policy limit $500,000
y E
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] 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 $ 16,348 4
Total Surcharges/Assessments $ $553.00
Total Estimated Cost S $16,901.00 j
INTERNAL USE SL Page - 1 - Information Page
MGA : R2WC053509 WC 000001A
Date : 09/13/2019
MANOTE
Issuing Office: P.O. Box A-H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
Registration: 181415
GREEN COLLAR LLC. Expiration: 03/31/2021
351 NEWTON ST UNIT B
SOUTH HADLEY, MA 01075
Update Address and Return Card.
CA 1 0 20M-05117
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
181415 03/31/2021 1000 Washington Street-Suite 710
GREEN COLLAR LLC. Boston,MA 02118
STEVEN ECKMAN
351 NEWTON ST UNIT B Not valid without signature
SOUTH HADLEY,MA 01075 Undersecretary
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-108817 Expires:OGIZV2020
8
ROBERT CALHOUN
390 NEWTON STREET
SOUTH HADLEY MA 01075 `
Commissioner