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32C-092 (2) 21 WILSON AVE BP-2021-0064 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:32C-092 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2021-0064 ProjectJS-2021-000092 Est.Cost: $2999.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(sq ft.): 4573.80 Owner. HELLWIG CHRISTOPHER Zoning: URC(100)/ Applicant. GREEN COLLAR LLC AT. 21 WILSON AVE Applicant Address: Phone: Inscurance: 351 NEWTON ST (413) 532-1817 W ' SOUTH HADLEYMA01075 ISSUED ON.7/20/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:I N S U LAT E ATTIC 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: FeeType: Date Paid: Amount: Building 7/20/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner I DepEy "^ City of Northampton Building Department ' 212 Main Street Room 100 INSULATION © Northampton, MA 01060 . n e 413-587-1240 Fax 413-587-1272 ONLY O� L 0 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 —Unit 0 Zone Overlay District Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: NnSt-Ou N2llw\g pry Name(Print) Current Mailing Address: e0Telephone Signature 2.2 Authorized A ent: f-( v(67 Name(Pr orozz Current Mailing Address: Sigature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2,9 Ci a C,'D (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) V 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) Z., Otq Q(, Check Number This Section For Officia g 0i?2W-oo4 N Date Building Permit Number: Issued. Signature: -7- IT 2020 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Acpplicabllee El Name of License Holder: 1 (�5 �l� t Licee ns e Numberr Sgo_,�Aj ( 101 Oto-75 912 D 2Ae Expiration Date 533-iii Signature Telephone Not Applicable ❑ Company Name Registration Number �1( N-e L�7�� S fi tn c ►� .313 I I a0),- I Address Expiration Date Le ��� dl6 75- Telephone Ut 3 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 In S+Cklla y 11 C01 t, 10 5'e to rl to t% Etat- tb as Owner/Authorized Agent hereby declare that the statements and infor' mation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. 20b 00-1 ha in Print 101 Signature of Own'tTtAgent 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 � ,;• i Massachusetts DEPARTNENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building P� 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 Vv., registered. ���� 2 `Z Type of Work:` Q 0 ,(�1?(�yl'� Est. Cost: .,aaa. Address of Work: 0 I W 1 &)n 41/`-Q Date of Permit Application: ' 210 - L q 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 sus- sic Massachusettstea,? J=- '<< `G ( '-,A � s DEPARTMENT OF BUILDING INSPECTIONS l 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: Z 1 Vu',1 Sar) OV( Wr*&Mig M A 01 6 lQ 0 (Please print house number and street name) Is to be disposed of at: ow V0cLq . D) P vrvt_e-,bt P--o aA (Please print name and location of facility) C-'-d Q � Or will be disposed of in a dumpster onsite rented or leased from: C (Company Name and Address) Signature of Permi plicant 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. City of Northampton Massachusetts f DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: of � V V 11 S On Contractor C6 /VU_r- L/'j Name: l� Address: City, State: �X1�r -n/A taa� V (0 0 Phone: Property Owner h s 1�,� r ICU Name: C Address: l WI �- City, State: I, 7LELVI C }� (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-& is a idavit. Contractor signature Date / / Owner AU-iharization Form �, C�R�STa p�� ��LLw►G (Owner's Name) Owner of the property located at: �( 1�/► `s� � JL 04�- mprorj Mtq ro6Q (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) �y /YQ✓ a01�? (Date) The Commonwealth of Massachusetts {{ Department of Industrial Accidents Ma I Office of Investigations k1W i 600 Washington Street Boston, MA 02111 www.massgov/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 employees(full and/or part-time).* have hired the sub-contractors 6. EJ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. ❑ $ required.] 5. ❑ We are a corporation and its 10.F] 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.[@ Othetinsulation/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. Insurance Company Name:_ AmGUARD Insurance Company - A Stock Co. Policy#or Self-ins. Lic.#: R2WC053509 Expiration Date: 9/23/2020 Job Site Address:_QQ I\IjCw l. City/State/Zip: s n kx 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 hereby certif under the pains and penalties of perjury that the information provided above is true and correct. Sianature: 0Date: Phone#: T43 532 1817 Official use only. no not write in this area, to he 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 Emolover!c Liability policy HathawayAmGUARD Insurance Company-A Stock Co. OLIVA/Berkshire004% Insurance sPolicy Number R2WC053509 I� GUARD Companies Renewal of R2WC988571 NCCI No. [21873], Policy Information Page (AR) [1]351 Newton St Unite Named Insured and Mailing Address Agency GREEN CALCAR LLC TIERNEY INSURANCE AGENCY INC. , $outh Hadley, MA 01075-2351 PO Box 750 Westfield, MA 01085 Agency Code: MATIER10 Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC) Risk ID Number 1038965 [2] Policy Period From September 23, 2019 to September 23, 2020, 12:01 AM, standard time at the insured's mailing address. F eraaWorkers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed n 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 Pians. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium Total Surcharges/Assessments 16,348 Total Estimated Cost $ $553.00 1dIEBdAI USE Ai $16-2-01.00 MGA :R2WC053509 Page- I - Information Page Date :09/13/2019 MANOTE WC 000001A Issuing Office:P.O. Box A-H,39 Public Square,Wilkes-Barre, PA 18703-0020 www.guard.com 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. Expiration: 03/31/2021 351 NEWTON ST UNIT B SOUTH HADLEY,MA 01075 Update Address and Return Card. CA 1 O NIA--MI? offlee of Consumer Aff dre a ausirms Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:LLC before the expiration data. If found return to: office of Consumer Affairs and Business Regulation 181415 03/31/2021 1000 Washington Street-Supe 710 GREEN COLLAR LLC. - Boston,MA 02118 STEVEN ECKMAN 351 NEWTON ST UNIT B Not valid without signature SOUTH HADLEY,MA 01075 Undersecretary Com nonweatth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-108817 Expires:08/23/2020 ROOERT CAL#KM 380 NEWTON STREET SOUTH HADLEY MA 0'W& awn Commissioner C"'4 e