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38B-067 (3) Department use only ity of Northampton Status of Permit: JAN 1 1 2019 uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability PT.OF BUILDING INSPECTIONS NO hampton, MA 01060 Two Sets of Structural Plans DE NORTHAMPTON•MA 01060 one 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION I This section to be completed by office 1 Property Address: y Map Lot 10 P17 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: , ('� L 110.nmoD 21 , p A YT Name(Print) Current Mailing 1 ddress: L41 - 8� 3q SEE ATTACHED DOCUMENT Telephone Signature 2.2 Authorized Agent: Green Collar, LLC 351 Newton St. Unit B.South Hadley, MA 01075 Name(Print) Current Mailing Address: 413 532 1817 SignatureTelephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building j (a)Building Permit Fee 2. Electrical / (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �dD 4. Mechanical(HVAC) �v 5. Fire Protection 6. Total= 0 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Insp ctor of Buildings Date ,;r C) t�6� Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage °N) (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW OX YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW g)X YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO (K X IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors I] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[MOX Brief Description of Proposed Work: INSULATION/WEATHERIZATION Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X_No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, SEE ATTACHED DOCUMENT as Owner of the subject property hereby authorize Green Collar, LLC to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED DOCUMENT t' to — 2,017 Signature of Owner Date 1, 4914'4 as Owner/Authorized Agent h reby 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. cc ll .ti Print am Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: CS-108817 License Number Robert Calhoun 8/23/2020 Address Expiration Date 390 Newton St. South Hadley, MA 01075 Signature Telephone 413 532 1817 9.Realstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Green Collar,LLC 181415 Address Expiration Date 351 Newton St. Unit B. South Hadley, MA 01075 Telephone 413 532 1817 3/31/2019 SECTION 10-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....... M No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780 Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State andel Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature /r{� City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 21'5 Sou,�h S�- The debris will be transported by-I"V2'--� C 1 YV ► C f S The debris will be received by: (Vic S Building permit number: Name of Permit Applicant 'Vo b ��l Y`bU•-�1 Date Signature of Permit Applicant Owner Authorization Form (Owner's Name) Owner of the property located at: j Property Address) (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. (Owner's Signature) (Date) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations -. ( 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Green Collar, 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 box: Type of project(required): 1.® I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.® OtherInsulation[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. #Contractors 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. #: R2WC855214 Expiration Date: 9/23/2019 """W� , y�/� 1 Job Site Address: I � �.t rf J City/State/Zip:1111641�1Yll 1 r &(A 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 her c ' uff&r ains and p s ofperjury that the in fifrntation provided above is:true and correct. Si at ire. Date: /—/0 Phone#: 4135321817 1817 Official use only. Do not write in this area, to be completed by city or town official 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 Contact Person: Phone#: Worker's Compensation and Employer's Liability Poli E �!'�Berkshire Hathaway AmGUARD Insurance Company - A Stock Co. y Policy Number R2WC988571 �' Insurance Renewal of R2WC855214 G U A R D Companies NCCI No. [21873] r Policy Information Page (AR) 4L4n�aqn is 40 [1]Named Insured and Mailing Address Agency GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC. 351 Newton St Unit B 16 NORTH ELM ST South Hadley, MA 01075-2351 Westfield, MA 01085 Agency Code: MATIER10 Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC) [2] Policy Period From September 23, 2018 to September 23, 2019, 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 Liability 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: 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 Limited 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 $ 10,852 Total Surcharges/Assessments $ 389.00 Total Estimated Cost 11 241.00 IiiTHftAL U$E__..IIX Page - 1 - Information Page MGA :R2wC988571 WC 000001A 04 ;09/o4/2018 MANOTE Issuing Offic'1110 P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020• www.guard.com Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constf ti'S0pervisor CS-108817 r . Expires:08123/2020 ROBERT CAL14M 3"14EWTON STREET, ; MOUTH HADLEY MA 011011 a.,Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, tZLhnusetts 02118 Home Improventractor Registration Type: LLC Registration: 181415 GREEN COLLAR LLC. I« W Expiration: 03/31/2019 351 NEWTON ST UNIT B M SOUTH HADLEY,MA 01075 a W H 4' �M see Update Address and RoWm Card. SCA 1 0 2OM-05/17 .7//P (ilNYl�illYtl/P4.C./![/�.0(�ClurJ/If,/liG�/`J office of Consumer Affairs 3 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:LLC before the expiration date. If found return to: Realstration Expiration Office of Consumer Affairs and Business Regulation 381415 03/31/2019 1000 Washington Street-Suite 710 GREEN COLLAR1iC " Boston,MA 02118 �;sem-moi STEVEN ECKMAN 351 NEWTON STt� SOUTH HADLEY,MK`0tb Not valid without signature Undersecretary r7 �