09-005 (4) 317 KENNEDY RD BP-2020-0929
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:09-005 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-2020-0929
Proiect# JS-2020-001580
Est.Cost:$843.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group GREEN COLLAR LLC 108817
Lot Size(sg.ft.): 131551.20 Owner: HANLEY RACHAEL
Zoning: RR(100)/WSP(100)/ Applicant. GREEN COLLAR LLC
AT. 317 KENNEDY RD
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 RIM JOIST
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:
FeeTvae: 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
ul
Dep
City of Northampton FtrB 4 `
Building Department
-
rr 212 Main Street,No9 y ?G ULATION
I'Y Room 100 r qT'!o,
r �
" Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 j 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:
Map Lot l/" Unit
Q Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
_ yA
2.1 Owner of Record:
Q- C.ti Ck e.Z. 31( 11 1Luy�(\Q d'A C
Name(Print) Current Mailing Address:
! A 3-(0 ;L alt to
(t{�I) a1ta(+\2 (�2 Telephone
Signature
2.2 Authorized Agent:
ky)eA 3s1 Wwtu\ 4�ree.E �csyk��lc�d,(��1 ►.,(
Name(Print) Current Mailing Address: 6
' AA'S - X32 -
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building p r f w (a) Building Permit Fee
2. Electrical o l (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)
Check Number
This Section For Official Use Only
/ Date
Building Permit Number: / Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: rNotApplicable ❑
Name of License Holder: Q�IyCA L l ( kUV �-/ —ms, -)61�t
License Number
tAM a $ 23 � 2d
Ad ress Expiration Date
9
Signal Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone 4'3 ,S-32- l b
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 LNGOTE: INSULATION ONLY
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
L
Signatur wner/Agent Date
CA lCL 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.
3(f , a"Cw J
Signature of Owner Date
City of Northampton
•% j Massachusetts x. G
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building JLH ,
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 d
�ith a corporation or LLC, that entity must be registere
Type of Work: l Azo Vv,, _ _ Est. Cost: _
Address of Work: 1 (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, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
SSS Sic" .
,w Massachusetts
c
W
DEPARTMENT OF BUILDING INSPECTIONS �- x
M
212 Main Street •Municipal Building wL pD`
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:
l a of
(Please print house number and reet name)
Is to be disposed of at:
(Please p(int name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Cat
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.
Permit Authorization
MSS save Form
Site ID: 3976073 Customer: RACHAEL A HANLEY
Rachael Hanley Hagerstrom
l� , owner of the property located at:
(Owner's Name,printed)
317 Kennedy Rd Northampton, MA 01053
(Property Street Address) (cam)
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.
Owner's Signature: /
Date: 2/1/2020
»s.w �,,.,»_•� ..,. m .�� �i�iM+Rii+f��Nr1�+�irlrll��M�itri�iMlli+Mr+4����►ii��i��rFii�!•
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office use Only
Rev. 102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
IF ww►v.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El please Print m er
A licant Informatida
ibly
Name(Business/Organization/hidividual): Green_Colar, 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 boxy Type of project(required):
1.® 1 am a employer with 4. ❑ I an:a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El7 I am a sole proprietor or partner- listed on the attached sheet. [JRemodeling
ship and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. employees and have workers9 ❑ Building addition
[No workers' comp. ins1lrance comp.insurance.t
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 I am a homeowner doing all work
right of exemption per MGL 12.E] Roof repairs
I
[No workers comp.
t c. 152, 1(4),and we have no
insurance required.]
. . employees. [No workers' 13.® OtherInsulation[Weatl►erization
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 policy and job site
information.
AmGUARD Insurance Company - A Stock Co.
Insurance Company Name:
Policy#or Self-ins.Lic.#:
R2WC053509 Expiration I)ate: 9/23/2020
Job Site Address:
(I d City/State/Zip: r-l'yV�cy��( �1 (✓l l
Attach a co of the workers' eompensa ' policy declaration page(showing the policy number and expiration date.
PY penalties of
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal p
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 the pains and penalties of perjury that the information provided above is true and correct
Signature: = Date:
Phone#: 43 532 1817
O,fJacial use only. Do not write in this area,to be completed by city or town o iciaL
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#•
�......�-�� io and EE p�r�Companya AStock bll�f Poles
Z At AmGUARD InsurancepolNumber R2WCOS3509
Berkshire Hathaway Renewal of R2WC988571
UARDInsurance NCGI No. [21873].
Companies
Policy Information Page (AR)
[1]Named Insured and Mailing Address ETI RNE�y INSURANCE AGENCY, INC.
GREEN COU-AR LLC p0 Box 750
351 Newton St Unit B
' 01085
Sth Hadiey,MA 01075-2351 AAgenncy Code
ouMATIER10
. Insured is Umited Uabiiity Co. (LLC)
Federal Employer's ID 47-1041086
Risk I0 Number 1038965
[2] 'policy Period
From September 23, 20Wto 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 Labilitylisur of our liability under this
rt policy
are:aplies to work in each of the states listed
in item [3]A. The $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/Assessments $ $553.00
Total Estimated Cost $16,901.00
Page- 1 - Information Paye
INTERNAL SE 8L WC 000001A
MGA :RZWCDS3509
Date :09/13/2019
MANOTE
lowing Office:P.O.Box A-H,39 Public Square,Wilkes-Barre,PA 18703-0020 o www.guard.com
usine
Office of Consumer Affair Street B Suite 710egulation
1000 Washington
Boston, Massachusetts 02118 tration
Home Improvement Contractor Reg'
Type: LLC
Registration: 181415
Epiradon: 03/31/2021
GREEN COLLAR LLC-
3"EWTON ST UNI"B
SOUTH HADLEY,MA 01075
a
Update Address and Return Card.
SCA 1 O 2CM45n7
01MO of Conaaaar,Marra 8,euskow Re8ub*m Regi vwm for Mdiviftuai use o*
NOME W-- ENT cONTRACTOR beton the sxpkaon dda• if found return to:
I 7M LLC Y ARWM and Buslneas Regulation
1311111111111010 1000 Washb9ton Street-guns 710
.. 0831/2021 Boston,MA 02118
GREEN COU.AR LLti—
35;NEWTON UNR S U Not valid without signaturO
SOUTH HADLEY,MA 61075 _ UndersecretarY
Commooweaith of Massachusetts
Division of Professional Licensure
r Board of Building Regulations and Standards
Constrtctl6n 160pervisor
CS-109817Upires:06123/2020
a
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