38D-015 (9) 20 CHARLES ST BP-2020-0928
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38D-015 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-2020-0928
Project# JS-2020-001579
Est.Cost: $774.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sa.ft.): 5488.56 Owner: MASON KATHERINE
Zoning URB000)/ Applicant. GREEN COLLAR LLC
AT. 20 CHARLES ST
Applicant Address: Phone: Insurance:
390 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:2/18/2020 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 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 2/18/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
S-
Dep
-"- City of Northampton \'
Building Departure t
�
NSULATION
212 Main re�,� 1 �_� I
t Room 100
' Northampton, MA 0 1/1.o, V
` phone 413-587-1240 Fax 413- � A
ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILYDWELL(G ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: is section to be complete by office
Map 310 Lot O�� Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
n
Name nnt) Current Mailin Address:
` Q. ajA OA C Telephone
Signature
2.2 Authorized Agent:
brit IQ Ntwtmlk �S
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ri .Lno (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee 4
�Q
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
®- .qac Date
Building Permit Number: Issued:
Signature: �` I
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable Q❑
Name of License Holder: l (LV(I� ✓� 0l 6 1 `
License Number
A0 N G,� �► h, u 114 01 Or' 8,23 . 24)
Address Expiration Date
Signat a Telephone
Q.Registered Home Improvement Contractor: Not Applicable ❑
0 r&A— Ca 11c�r � SLC, it 1 LI I�^-
Company Name Registration Number
Address a
n Expiration Date
Telephone4i3•Sa2 Ig I I
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
Jkt40-U O Kiln JOIJAOt CW(-' 'tb
-t-0 G'vv-o 1
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 Odrner/Agent Date
, 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
F, G
w �
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJs CD
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.
II
Type of Work: t U 11 fi✓� 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:
EvfCQLk ar, Lot I l Ll
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
r ' Massachusetts
h4 DEPARTMENT OF BUILDING INSPECTIONS D.
yJ
.' 212 Main Street *Municipal Building
Northampton, MA 01060 fN{y 301
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:
14ff ja ux_% am ?tm
(Please print house num er and street name)
Is to be disposed of at:
(Please print name andlocation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature 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.
2/6/2020 Kate PA.svg
Owner Authorization Form
1
(Owner's Name)
Owner of the property located at:
2- k c�-.l-e s
(Property Address)
�I1n a V0 �, 0 ( c)
(Property Address)
hereby authorize Green Collar , a certified Mass Save Home Performance
Contractor,to act on my behalf to obtain a building permit and to perform
work on my property.
JK�
(Owner's Signature)
/Z 2-0 Z -2,0-Z 0
(Date)
1/2
file-///C:/Users/info/Downloads/Kate PA.svg
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
ww►a.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EI Ple se Print Le bl
Applicant Informati
Name(Business/Organization/lndividual): Green Collar LLC
Addiess: 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.® 1 am a employer with 4. Q I am a general contractor and 1 6 El New construction
employees(full and/or part-time).* have hired the sub-contractors 7 Remodeling
2.ElT
I am a sole proprietor or partner- listed on the attached sheet. ❑hese sub-contractors have 8. E] Demolition
ship and]lave no employees
employees and have workers q, [:] Building addition
working for me in any capacity. comp,insurance.$
[No workers' comp. insgrance 5 ❑ We are a corporation and its 10.E] Electrical repairs or additions
required.] officers have exercised their 11.[]Plumbing repairs or additions
3.El am a homeowner doing all work t of exemption per MGL
myself. [No workers comp.
right 12.[] Roof repairs
c. 152,§1(4),and we have no
insurance required.] t employees. [No workers' 13.[M 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 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 is providing workers'compensation insurance for my employees Below is the pokey and job site
information. AmGUARD Insurance Company-A Stock Co.
Insurance Company Name:
Policy#or Self-ins.Lie.#:
R2WC053509 Expiration Date: 9/23/2020
Job Site Address:
ab uA City/State/Zip: Lf X-Wln���00(o6
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration datees of).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pe
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 Me pains and penalties of perjury that the information provided shove is true and correct
u Date:
Si afore: -
Phone#: 41345321817
Ofj`wkd use only. ho not write In this arta,to be completed by city or town oflkial,
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
e
6.Other
--- Phone#:
.lZsr Bion and mnlover's Liability_P�IklC
AmGUARD Insurance Company-A Stock Co.
Berkshire Hathaway policy Number R2WC053509
Insurance Renewal of R2WC988571
UAR® Companies IVCCI No. [21873].
`e Policy Information Page(AR)
[1]Nat"d Insured and Mailing Address AERN INSURANCE AGENCY, INC.
cy
GREEN��t�C
351 Newton St Unit B PO Box 750
' South Hadley,MA 01075-2351 Westfield, MA 01085
Agency Code: MATIER10
Federal Employer's ID 47-1041086 Insured Is Umited Uability Co. (LLC)
Risk ID Number 1038965
[2] -Volicy Period =
1 AM, standard time at the insured's mailing
From September 23, 20Wto September 23, 2020, 12:0
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 Uability 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: 500,000
Bodily Injury by Accident- each accident #500,000
Bodily Injury by Disease-each employee 500,000
Bodily Injury by Disease- policy limit $
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
[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
Total Surcharges/Assesoments $ $553.00
Total Estimated Cost 16 901.00 Page
ll�USE 81. Page- 1- Infowc 000001A
MGA :RMC053509
D*e :09/13/2019
MANOTE
Issuing Office:P.O.Box A-H,39 Public Square,Wilkes-Barra,PA 18703-0020•www.guard.com
1
Office of Consumer Affairs andBusiness Regulation
1000 Washington Street
Boston, Massachusetts 0211
Home Improvemeflt contractor Registration
Type: LLC
Re8ldmtion: 181415
E)piration: 03/31/2021
GREEN COLLAR LLC.
36"EWTON ST UNIT B
SOUTH HADLEY,NIA 01075
a
Updab Address and Ratum Card.
SCA 1 0 2OMMy-0sn7
0"ke of ConwrwMdrs i auslnsss RNal tion Rpm v*U for Indivloual use only to:
HOME IMPROVEMENT CONTRACTOR before 1M deft. N found return
yVPE:LLC ofltct of Carsumer I►ffaks and Businesspalation
1000 Was f,Ington Strad.Sults 710
p431/2021 Boston,MA 02118
GREEN COLLAR LLC.
STEVEN ECKMAN CNot valid without signaturo
NEWTON ST M 5 Undersecre
SOUTH HADLEY, (h07fefY
SO =
Commonwealth of Massachusetts
pNiaionquil in professional s and Standards
j Board of Building Regul
Constr4x&n 160pervisor
CS-108317 F«pirs:03/23/2020
RO�ItT CAt,�10� •j.:
Z.
oom MIADI.ET' 0
Cemndssioner C'
•