30B-040 (5) i
14 LIBERTY ST BP-2020-0774
GIs#: COMMONWEALTH.OF MASSACHUSETTS
Map:Block: 30B-040 CITY OF NORTHAMPTON
I 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-2020-0774
Project# JS-2020-001341
Est.Cost: $2737.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq. ft.): 11194.92 Owner: NTETA TATISHE
Zoning: URB(100)/ Applicant: GREEN COLLAR LLC
AT: 14 LIBERTY ST
Applicant Address: Phone: Insurance:
390 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:1/6/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.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:
I Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
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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:
FeeType: Date Paid: Amount:
Building 1/6/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Dep �
,,- City of Northampton lid
� Building Department
t,g 212 Main Street
INSUL T"I 'lo",
6611
Room 100
Northampton, MA 01060 �s tkli
/ phone 413-587-1240 Fax 413-587-1272
rs
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
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SECTION 1 SITE INFORMATION INS ULA TION PERMIT.
This`sectionto be'completed by office
1.1 Property Address:
1_ /1� ! Ma 66 Lot V' �v
l 4- L, U ��fQ.Q p Unit
�l 6Y�Cj- , ry(�tq- Q� 6.q 'Z : Rorie ''" overly Qistria"t
Elm St,District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailineddresk 3k
SV ' n " J
� P aA+Q& 'ed Telephone
Signature
2.2 Authorized Agent:
C l L 4
Name(Pri ) Current Mailing Address:
X13 -532 TI-7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building t r) (/D (a)Building Permit Fee
2. Electrical (b)Estimated Total.Cost of
Construction from 6 E
3. Plumbing Building Permit Fee I
4. Mechanical(HVAC) (Jr
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
on 121'
7
Signature: l9
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED;,EITHER HOMEOWNER OR CONTRACTOR)
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City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building Ok
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.
j Note.If the homeowner has contracted with a corporation or LLC,that entity must be'registerea�
Type of Work: ) U 1 e4+) UVU Est.Cost:
I ��
Address of Work: ILA Ix�a��L
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:
rtm Co a a
ate Contractor Name * R1stron .o.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner ofproperty:
above
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Date Owner Name and Signature
City of Northampton
Massachusetts
w� l�
DEPARTMENT OF BUILDING INSPECTIONS y x
212 Main Street •Municipal Building Jd,1 fi;-Ca
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:
(Please print house number and Weet name)
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Is to be disposed of at:
bl L st r��c:2�s �vY vwd� (-d
(Please print name and location of facility)
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Or will be disposed of in a dumpster onsite rented or leased from:
C1 rtu2 ' N-A D
(Company Name and Address)
ignature 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.
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City of Northampton
Massachusetts
�� he
V!:
DEPARTMENT OF BUILDING INSPECTIONS DyJt
s
r 212 Main Street • Municipal Building dfs ;Oc
m. Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: tq Lk WA- �
Contractor
Name:
I
Address:
City, State: `' GO�� VA
Phone: 41,b l K
Property Owner
Name: � ca
Address:
City, State:
1, (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
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RISE,
ENGINEERING
OWNER AUTHORIZATION FORM
I, Tatishe Nteta
(Owners Name)
owner of the property located at:
14-Liberty Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize
(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.
Owners signaftNb
LOZ�z/ /
Date
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RISE Engineering,a Division of Thielsch Engineering, Inc. .
60 Shawmut Road Unit'2'J'Canton,MA 02021 339-502-6335
www.RISEengineering.com
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A no%,VMf8VIH4's W"n Vj fel/ff,.7W.fiM.)f'N.1
De w*xentofIndu bid Accidents
tQfflce ofinvadgadow
600 Washington smea
Rostbnv MA 02111
www. gov/dila
Worlww Compena gim Insurance Affidavit:BuRders/Contractors/Electdciana/Plambers
Abolicaat Information Please Print Legibly
Ntune t ua' 'oal>ouvidbrd): Green Collar,LLC
� I
Address: 35I-Aleiwton St Unit B
C' 2tArlZl : South Hadley,MA 01075 Phone#: 413 5321817
Are yon aaanpiayrr.Cheek Me appropriate box: T3 pe of project(requiraq: v
a emnp1oyer with_ 4. ❑ I am a general c(mtractor and I `G. ®New construction
employm(full and/or part-time).* have hired the sub-camrectors
2.❑`I am a sole proprietor or partner- -
listed ow&e attached sheet 7. ❑Remodeling
These sub-oamhactors have L [3 Demolition
sad rIIO ° ,emp14p.and have workers'
working for, in any capacity.- comp.iasur�$ 9. Building addttian
[No worloers'comp.inatuance_ 5. 0 We are a corporation end its 40.0 Electrical repairs of additions
��-] officers have exercised they 11. P
El I am a homeowner doing all work ❑� lambing repairs or additions
myselE[No v,orken,ca mp. right of exemptionperMGL 12.E Roof repaiin
insurance required.]t c.152,§1(4),and we have no MIN Odierinsulation/N/eathetization
- - employees.[No workers'
� �inso�ce •]
*Aay gVHc t deet etndu baa dl mot Ww fill out the toctiaet below d owmg dm&wwWe em pmotm Polio'mfase Bfm
t HomoMw "D saI—tw1 afbvit dwy=do ft all wak sed thea bile aWdde osnf cWm mast emI '-&naw d NIa*Mcg a4 .
=Camoetas d 0check dds bw nest at wW=additional,beet showing the moan ofdw sat-ooh ud cute wbedeer ar not those entities�enve
e�mpbyees. ffftM&CMvMWMhMCMPhWWs,theyn=p Wvdmdrwwkw.camp.policynumbs
1 aar.n eaepfo, and is ntariFara'cbairparsattion bi nmrc�for.ry�pdopaes. Below is awpe tcy awd lob site
INjbnWdM
inanrence company Name: AmGUARD Insurance Company-A Stock Co.
7'icy#or Self-ins.Lic.#: R2WCOMM Expiration bate: 9x 2020
,lob Site or
14- U btA i W 2c; 4 city/StakrAp: fA M CO- C)lQ 2
Attach•copy of the workers'eompematlhn policy deftmilen pop(showing the policy amber and e:plradoa date).
Paihme 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$1,50000 and/or one-year in*isonment,as well as civil penalties in the form of a STOPS WORK ORDER and a fine
f upQ to S.00 a day against the violator: Be advised 110-a copy of this statement may be forwarded to the Office of
ma of the DIA for in meats coverage verification.
Ida kreby effo wrdw9 ke vrd p olp�'xry t dm arfonrah'oe provtldad obov�e is mire c cosra�
413 5321817
OBidsd am o»tit. Do mw wift is dila.wv4 to be erasrpdded by carp or Awn of 9deL
City or Town: Permit/ censm#
Issuing Aut bority(drde one):
1.Boated of Health 2.Bdftg Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Iaspactor
6.Other
Contact Person: Phone#:
Vloorkees Compensation and Employees Liability owliwo
Berkshire Hathaway AmGUARD Insurance Company-A Stock Ca
GUARDInsurance policy Number R2WCOS3501
Compariles Renewal of R2WC988571
NCCI No. [21873;
a Polley Information Page(AR)
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[1]Namsd Insured and Mailing Address Agency
P51 N Con St nit 77ERNEY INSURANCE AGENCY, INC.
351 Newton St Unite PO Box 750 '
;�oudr Hadley,MA 01075-2351 Westfield, MA 01085
Agency Code: MA77ER10
Federal Employer's ID 47-1041086 Insured is Umited Uability Co. (LLC)
Rlsk ID Number 1038965 .
121 iio114 Period
From$eptemktpr 23, 2019 to September 23, 2020, 12:01 AM,standard tome at the Insured's mailing
address.
[33 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- Pant Two of this policy applies to work in each of the states listed
In item[33A. The Ilmits'of our liability under Part 7Wo are:
.Bodily Injury by Accident-each accident $500,000
Bodily Injury by Disease-each employee 4500,000
Bodily Injury by Disease-policy limit $500,000
C. Refer to Residual Market Umited Other States Insurance Endorsement-WC200306B
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
[43 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)
Y®tal Estimated Polley Premium �; i6,341g
Totao Surchupea/Assessments
Total ftdmafad Cost 116,901.00
Ielzr usE e
MSA :R2WC053509 Page- 1 - Intonation Page
Dere :09/13/2019 WC 00=1A
FIdIMQ11'E
ImIng office:P-0-80Z A-H,39 Public Square,WIIIcma-Sarre,PA 18703-0020•Wm guord.00m
0130
Aa ax�W,2
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. E)Iratlon: 03/31/2021
351 NEWTONST UNIT B
SOUTH HADLEY,MA 01075
b _
-
Updsb Addnns and Ratwn Card.
CAI 0 20*05n7
orAa of Cora=Wlvrslrs a R+o�O" valid far Irrwtdwt un only
1�OINE NPROVEIAENT coNf RAC rOR 1bgwq*aSrr dds. N round rebam W.
TYPE.LLC of m of consumer Affe*s and Bustnsss RspuNation
t lbodilm -4 1000 Washlimshm Stud-Su is 710
Boston,MA 02118
GREEN COLLAR"
351 NEWTONR SST UNFN'g `
Not valid without signature
SOUTH HADLEY,MA 01075 - UndersecratmY
CafferA mIth of Massachusetts
Diuisbn of Professional Licensure
Board of Building Regulations and Standards
Construction'supervisor
• CS-10,817 spires:OSJr?,31?AZ0
il1MONt 't'r •.,h 1�a
. t101fifl @4'iD1.E�t'ER 01� ,'
C=Mh" oner
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