24A-163 (3) 329 PROSPECT ST BP-2021-1009
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 163 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-2021-1009
Project# JS-2021-001399
Est.Cost: $4844.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq. ft.): 13460.04 Owner: NEIMAN KENNETH P
Zoning: URA(100) Applicant: GREEN COLLAR LLC
AT: 329 PROSPECT ST
Applicant Address: Phone: Insurance:
351 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:3/16/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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 NO 'TH• PTO UP VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. I
' . • S
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 3/16/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
�'�,': ^,, Department use only
City of Northampton" atus of Permit:
Building Department 4,45) L'Cuff Cut/Driveway Permit
212 Main Street �S wer/Septic Availability
Room 100 `:_'*� S, Wate7t'/Well Availability
Northampton, MA 01060 9/ iwirf Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1.272 I (ot/Site'Plans
(Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE.OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION . !- (a l
This section to be completed by office
1.1 Property Address:
Map Lot ( Unit
3a� PCoSQx+ `"Aroma}
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r,o,h 37).-k PrdsPac.4 SA_
Name(Print) Current Mailing Address:
9/.3 - S 3-/- V14-1
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Apent:
Green Collar, LLC 351 Newton St. Unit B.South Hadley, MA 01075
Name(Print Current Mailing Address:
i 413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
+ 844,4
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee #69(
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) $ y grit/ Check Number 1y73
This Section For Official Use Only
/
Building Permit Numbe : DateIssued:
Signature: 3"15"2O Z J
Building Commissioner/Inspector of Buildings Date
qc
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
(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 0 DON'T KNOW OX YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
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 60X YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O 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 O
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 O NO g 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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [1=1 Siding [D] Other[®]X
Brief Description of Pro�pposed
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
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 /g,/A,k
Signature of Owner Date
Rob Cat l h ,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.
Ob
Print Name
3/g/ada,
Signat re of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: CS-108817
License Number
Robert Calhoun
81�-3f2e2e— $jA31 as
Address
Expiration Date
390 Newton St. South Hadley, MA 01075
Signature Telephone
413 532 1817
9.Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
351 Newton St. Unit B.South Hadley, MA 01075 Telephone 413 532 1817 `3f3Y/2UT9 3/3113.03,I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes )$( No 0
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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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: 3a\ QtosQ'Dc-i, f-+
The debris will be transported by: Gr 4-02 v‘ CC r
The debris will be received by: Cr oe - Ca co/i IL/ brr‘c4e S-+ . seativ ,, M^ a``
Building permit number:
Name of Permit Applicant Rob Ca l ho V
Date Signature of Permit Applicant
• The Commonwealth of Massachusetts
...^ Department of Industrial Accidents
WNW =,.� Office of Investigations
ft EaLM 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: 570 Newton St
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 /S 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 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P Y 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑X 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.
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.
Insurance Company Name:_ AmGUARD Insurance Company - A Stock Co.
Policy#or Self-ins. Lic. #: R2WC 182010 Expiration Date: 9/23/2021
Job Site Address: 3),q or.,,(..1 SJJ 4- City/State/Zip:pot-11N.AA,421c1^, iw4 nb(,�i
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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Signature:
/ Date: 3 J� o
� ���-�_
Phone#: 413 532 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#:
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Registration: 3
351 NEWTON ST UNIT B Expiration: 0 03//311/2/2
021
SOUTH HADLEY,MA 01075
Update Address end Return Card.
SCA 1 a 20M.05117
.74 yP//./iI/v,","r�/�P/.��U•iigr�Uir��i
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
181415 03/31/2021 1000 Washington Street-Suite 710
GREEN COLLAR LLC. Boston,MA 02118
STEVEN ECKMAN \IQ CSa--
351 NEWTON ST UNIT B (�
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
ConstructibnSupervisor
CS-108817 Expires: 08/23/2022
ROBERTCALHOUN ����� pry
8 UPPER RIVER RD i
SOUTH HADLF.Y MA 01076
Commissioner defeai. BtnJ.a...
Worker's Compensation and Employer's Liability Policy
AmGUARD Insurance Company - A Stock Co.
!Berkshire Hathaway Policy Number R2WC182010
11i G u A RD Insurance Renewal of R2WC053509
�•A Companies NCCI No. [21873]
Policy Information Page (AR)
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC AMHERST INSURANCE AGENCY INC
370 Newton St PO Box 48
South Hadley, MA 01075 Amherst, MA 01004
Agency Code: MAAHER10
Federal Employer's ID XX-XXX1086 Insured is Limited Liability Co. (LLC)
Risk ID Number 1038965
[2] Policy Period
From September 23, 2020 to September 23, 2021, 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 $ 21,496
Total Surcharges/Assessments $ $728.00
Total Estimated Cost $ $22,224.00
INTERNAL USE xx Page - 1 - Information Page
MGA : R2WC182010 WC 000001A
Date : 09/11/2020
MANOTE
Issuing Office: P.O. Box A-H, 39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.com
D'cuSign envelope ID:47E357B5-E9D3-4C20-B74D-9B2A9DAA117D
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
Janice Neiman
(Owner's Name)
owner of the property located at:
329 Prospect Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize
Subcontractor(to be filled in by office)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
c—DocuSigned by
AtiKiaaA,
ot\7 6 's gf f are
1/15/2021 111:01 AM EST
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 ) Canton, MA 02021 J 339-502-6335
www.RlSEengineering.com