23D-044 (6) 100 RIVERSIDE DR BP-2020-0749
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-044 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-2020-0749
Proiect# JS-2020-001292
Est.Cost: $3099.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group GREEN COLLAR LLC 108817
Lot Size(sa.ft.): 4660.92 Owner. WEINSIER LAUREN B&STEVEN T
Zoning: URB(100)/ Applicant. GREEN COLLAR LLC
AT. 100 RIVERSIDE DR
Applicant Address: Phone: Insurance:
390 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.12/23/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC INSULATION
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 Sienature:
FeeType: Date Paid: Amount:
Building 12/23/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
�S �v
Dep
aff
City of Northampton
Building Department
212 Main Street
,r Room 100 SULATION
Northampton, MA 01060 ' 0 �� %
phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO r ING ON/ LY
SECTION 1 -SITE INFORMATION INSULA N PERMIT
1.1 Pro
This section to be completed b office
rpCe�r�ty Address. �L
I U U fj\J-e f S Ictk b 1 vu Map Lot—(/`
ot (/`J / Unit
�l o nn , � O lo
( Zone Overlay District
`�• Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6-b �)Cy-erl ce. R&R 01 o to a
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
-ILfIt) -5 IVP n S
Name(Pri:4x
Current Mailing Address:
L4 L3 IT/ 7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building O( (a)Building Permit Fee
2. Electrical (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) w Check Number
This Section For Official Use Only
Building Permit Number: Q 7 DateIssued.
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
Not AAppplicable ❑/`c,��y"
Name of License Holder: F�/r�C/ W� �y `- V O k
License Number
Address Expiration Date
Dix- (Z I q
Signaturg Telephone
Not Applicable ❑
Company Name Registration Number
(14-0A Mall- �/at 3 / �
Address
1 V ss A f D�1 Expiration Date
u eWt7A Telephone 913-&-a-iLlrl
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
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.
cj
Print Name �
-]� L
Signature of Own /Agent 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
S�5 r~ SSC
Massachusetts2 ..
.,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building yJr O�
Northampton, MA 01060 rsYn `�o
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:
k Y S, 2lbs( v f,
(Please print house number and street name)
Is to be disposed of at:
C CV\1 d,A IPO lol I G W V �Q� (a r Z ^ '3 , C►^^
(Please int name and location of facility) M
Or will be disposed of in a dumpster onsite rented or leased from:
C'1 r u \. (��k V bs) �\tu)VA 1-'W t l--6 l 0.�Le't
(Company Name and Address) Q
i'
Si nature 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 ' .
A ' w
DEPARTI004T OF BUILDING INSPECTIONS N*
212 Main Street • Municipal Building t1t astir
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 registered.
Type of Work: y)a,-d'-Gyo _ Est.Cost: 3Tu�C1 1-�
Address of Work: ^ \( e l( S t�J� ✓ ► VK Ft U rtl\ CP- 0 1
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:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
2S`S Sj
Massachusetts
^� DEPARTMENT OF BUILDING INSPECTIONS y� a
212 MainStreet • Municipal Building
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: sEG)=t Dri,yt R(AleAa t 14 �AV ()JOWL
Contractor
Name: �f-UA Our
Address: N e,W SCC n � QiC
City, State:
Phone: 2 - R
Property Owner I ,
Name: U �� UJeI ►� SIS(
Address: ( 03 �A Vf1c t OLL
City, State: Hcd tY-L CQ, hn 01 G lQ 2
(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 1 'J
lJl �7
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Lauren Weinsier
(Owner's Name)
owner of the property located at:
100 Riverside Drive
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize (?AV,� &,�U)
(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
Da'ttee
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.RISEengineering.com
Ana W-UM UnryCm"s UJ[It iiJJfii,/LMJGfiJ
Department of Industrial Accidents
OJ,lce of Invesdgadons
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant formation ltbl
Name(Business/Organ=tlon/Individual): Green Collar LLC
Address: 351-Newton St. Unit B
413 532 1817
City/Stapte/Zip• South Hadley,MA 01075 Phone#:
--
Are you ancmployer?Check the appropriate box: Type of project(required):
4. E] I am a general contractor and I New construction
1.® I am a employer with - � have hired the sub-contractors 6' ❑
employees(full and/or part-time). q. Remodeling
2.❑ I am a sole proprietor or partner- listed on-the attached sheet. ❑
These sub-contractors have g, [J Demolition
ship and havg no employees
working for me in any capacity._ employees and have workers' 9 C]Building addition
[No workers comp:insurane
comp.insurance. 10.❑ Electrical repairs or additions
required.] 5. 0 We are a corporation and its
re
3.El I qu a homeowner doing all work officers have exercised their 11.[)Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ Rood repairs
c. 152,§1(4),and have no
insurance required.]t employees. [No workers'
kers' 13.® Othednsulation/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 afndavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContmctors 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 poucy andjob site
information.
AmGUARD Insurance Company-A Stock Co.
Insurance Company Name:
Policy#or Self-ins.Lic.M R2WC053509 Expiration Uate: 9/23/2020
Job Site Address:
n 4 v ef S l&e City/State/Zip: � Uf P1� � � � G� 0k
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 certhjy render the " dant penalties of perjury that the information provided above is true and correct
Si Date: 1
Phone M 413 532 1817
[r6.0ther
al use only. Do not write in this.ama,to be completed by city or town oJrciaL
r Town: PermitlLicense#
g Authority(circle ens):
]1uspectorrd®f Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing
ct Persaia. Phone#:
Mrker's Compenmtlon and Emo oyer's Lj0h11*V pWi
kGUARDCornpanles
erkshire Hathaway Aar Insurance Company-A Stock co
Insurance Polity Number R2WC0535o!
Renewal of R2WC98857i
NCCI No. [21873;
e
PONcy Information Page(AR)
111N8m6d Insured and Walling
Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit a PO Box 750
$oath Hadley,MA 01075-2351 Westfield, MA 01085
Agency Code: MATIERIO
Federal Employer's ID 47-1041086 Insured Is Umited Uability Co. (LLC)
Risk ID Number 1038965
121 Policy Period
From tepterntier 23, 2019 to September 23, 2020, 12:01 AM, standard time at the Insured's mailing
address.
F
erage
Workers'Compensation Insurance- Part One of this policy applies to the Workers'Compensation
law Of_the following states: Massachusetts
Employers Liability Insurance- Part Two of this policy applies to work in each of the states listed
n 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
Bodily Injury by Disease - policy limit $500,000
C. Refer to Residual Market Umited Other States Insurance Endorsement-WC2003068
D. This policy Includes these endorsements and schedules:
See Extension of Information Pave -Schedule of Forms
=audlt.
asis and, therefore, the premium will be determined by our Manual of Rules,
Rates,.and Rating Plans. All required information Is subject to verification and change by
ed on another page)
Total Estimated Policy Premium $ 16,348
TOM Surcharges/Asswments
Total Estimetad cost $ #553.00
16 901.00
NW R2WCO350 Page- 1 - Information Page
Date :09/13/2019
MANN E WC OOOOOlA
iseuing Office:P.O.sox A-N,f Ejbiic SCIMM MlUkes-Barry PA 18703-0020 0 www.guard.com
c
_ �
' �i e�•�P. �� l.�Gz:4��lt��-/���CLc�J���e���fr.�P��.�
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
i
+ - Updda Address and Return Card.
CAI ® zoaraam
3
OMN of Commer Miele s SOW"R"00"on vaild for in�vWud un only
HOME RMPROVEMENT CONTRACTOR , ff Lound return to:
TYPE:LLC OM=of CorrNanar Aff*8 and&Wnass Rapes+
151415 03/31=1 1000 tl-1—M.—mr Strad-501b 710
soatora MA 0211a
GREEN COLLAR LLC-
STEVEN ECKMNd ` '
351 NEWTON ST UNIT® VSIId WIIONt signature
SOUTH HADLEY.MA 01075 Undersecretary
Cormmm0fNh of Massachusetts
Division of prohssional Liconsurs
Board of Building Regions and Standards
Construction Supervisor
CS-108817 wires:OW23/2020
ROBERT CAL110LO
308 NEYYrON STRw
SOUTiq N40Lt'e1F NIA 0"76
w
Commissioner