25A-090 (9) 38 COOLIDGE AVE BP-2020-0927
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-090 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-2020-0927
Proiect# JS-2020-001578
Est.Cost: $1714.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 6708.24 Owner. WEIHRAUCH DOUGLAS M
Zoning: URB(100)/ Applicant: GREEN COLLAR LLC
AT. 38 COOLIDGE AVE
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 KNEEWALL
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
U
DepAW
City of NorthamptotlOR
Building Departme Q
212 Main Street,,0op4SULATION
�r .�,�
� f Room 100 \q.t,arn,�/n
�A q
Northampton, MA 01060 Y qo�
rir phone 413-587-1240 Fax 413-587-12 %s
ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
This section to be completed by office
1.1 Property Address- O 1
Map CJ`�A Lot 0 -Unit
-
A Q�U(Jt
C
, j3V �W��, � 0� () (-0Zone Overlay District
Elm St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1 V
Dn W e, In r w ?�� r�_ Ud ►ire, (����ha n �1,t.�a���o
Name(Print) { 0 ��� Current Maaii�lin�g Addre�s7: n n
Telephone
Signature
2.2 Authorized Agent:
P Obej t
Name(Print) Current Mailing Address:
J 52
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed hy permit applicant
1. Building ' �1 N l" (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) r( 1 Check Number
This Section For Official Use Only
�,. C pf 7 Date
Building Permit Number: �� Issued:
Signature: JAL 0
Building Comm issionerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: n� Not Applicable ❑G
Name of License Holder: P(�Y1� �n Lh�l�Y (LC, 1�.L61 1 1
License Number
Address J Expiration Date
�� 3- X32' 1 �l rl
Signatu a Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
-C�st fju Pau , LL C. 1 S111-\�
Company Name Registration Number
3s1 eW I Ir-L-- aN-�� "ahm Ult-T a,0!�-- 3.31.2
Address U xpiration Date
TelephoneA�3-'t�52- 1 g 1
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
11�a.U. 21% �►5�� 1300-rd
*t VKukkfictu
Oak h Nj tAl ) ,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 per ury.
Vob rt Oat. w✓�
Print Name
�� I tv L
Signature of ner/Agent Date
,X'k
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 ��2 - <<
N k.
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
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: IYI.A J1 Qt G7 Est.Cost: l ( �
Address of Work: &A �(�N�h-Y"`� _CA7Y)Tftt/ o)0
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:
ulo k cQ hn of
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
F.
G
a DEPARTMENT OF BUILDING INSPECTIONS a-
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:
<3s t�A a 0 (- i k W('X-�ll,� ,
(Please print house 16mber and treet name)
Is to be disposed of at:
(Please print name and I ca ion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Perm p icant 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.
2/11/2020 Doug PA.svg
Owner Authorization Form
(Owner's Name)
Owner of the property located at:
3� C-6611 & NgMI ,
(Property Address)
(Property Address)
hereby authorize Green Collar La certified Mass Save Home Performance
Contractor,to act on my behalf to obtain a building permit and to perform
work on my property.
(Owner's Signature)
(Date)
1/1
filp,///('.-/Li.,;Prs/info/Downloads/Douq PA.svq
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber se Print
Applift
cant Informatid�n
Name(Business/Organization/Individual): Green Collar LLC
Adt$ess: 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 4. ❑ I am a general contractor and I 6 E]New construction
employees(full and/or part-time).* have hired the subcontractors Remodeling
2.❑ I am a sole proprietor or partner- listedTsted on the attached sheet. E]hese sub-contractors have 8. [] Demolition
ship and Ilave no employees
working for me in any capacity. '. employees and have workers' = 9. ❑ Building addition
insurance.
[No workers' tromp. insurance comp. 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its _
3.❑ I am a homeowner doing all work
officers have exercised their 11.❑Plumbing repairs or additions
right of exemption per MGL 12.❑ Roof repairs
I
[No workers comp. and we have no
insurance required.].t c. 152,employees.
[No workers' 13.®Othednsulation/Weathe1ization
. employees. [
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.
lContractors 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.Lic.#:
R2WC053509 Expiration gate: 9/23/2020
3 C`ob t a �
Attach a copy of the workers'compensation policy declaraCity/State/Zip:l.�ru�an/��,�p}-rKl, 11 �' 0 0I,()
Job Site Address: c
tion 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.
Ido hereby certify urifer the and penalties of perjury that the information provided above is true and correct
Date:
Si ature: -
Phone#: 413 5321817
Of trial use only. Do not write in this area,to be completed by city or town offkiat
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
_ Phone#•
---p ion and Emolo ees LiabilibLF4lhm
Insurance Company A StOCK Co.
AmGUARD
Berkshire Hathaway Policy Number R2WC053509
Insurance Renewal of R2WC988571
GUARDCompanies NCCI No. [21873]
Policy Information Page (AR)
[g]G ed IREEN nsured and Mailing Address TI
�ncy
ERNEYY INSURANCE AGENCY, INC.
j LLC
351 Newton St Unit B PO Box 750
' south Hadley,MA 01075-2351 MA 01085
Agen
cy Code: MATIER10
Federal Employer's ID 47-1041086
Insured is Umited Uability Co. (LLC)
Risk ID Number 1038965
[2] 'policy Period
020, 12:01 AM, standard time at the insured's mailing
From September 23, 20194to September 23, 2
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 Uabliity 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 Surdlarpas/Assemments $ ;553.00
Total Estimated Cost *1.6J901.00 _
Infix.,
INTERNAL DISE 8L Page- 1-INTERNALC 000001A
MGA :RZWC0535M
Date :09/13/2019
MANaTEis • uard.00m
suing Office:P.O.Box A-M,39 Public Square,Wilkes-Barrs,PA 18703-0020 www.g
JAaj
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u
Office of Consumer Affairs andBusiness lRegulation
1000 Washington Street
Boston, Massachusetts 02118
Home improVement Contractor Registration
LLC
aType. 81415
RegistmWn: 1
E)pimdon: 03/3 1/202
GREEN COLLAR LLC.
35'r1dEWTON ST UNIT B
SouTH HADLEY.MA 01075
Upd6a Address and Rin Card.
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1R021 SosfoM MA 02118
GREEN 000.AR114w'-
STEVEN s cNat va8d signatUr
SOUTH HADLEY.mA 6075 _ UndUnd
Comwnwalth of Mmssdwsstfs
Division of p"O"sionsi and Sts�ildsrds
Board of SuNdMq R�INions
ConstrVe6n,japsrvisor
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