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25C-086 (4)
12 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS BP-2021-1942 Map:Block:Lot:25C-086- 001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1942 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 6607 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: DUNN, KAREN S Lot Size(sq.ft.) Zoning: URB Applicant: GREEN COLLAR LLC Applicant Address Phone: Insurance: 570NEWTON ST (413)532-1817 R2WC1182010 SOUTH HADLEY, MA 01075 ISSUED ON:09/24/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERIZATI ON 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. Signature: el • 502 T-11 • Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildinc Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 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 This section to be completed by office 1.1 Property Address: is Ii1-ICcth AO(' Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: k0.112 u Y1 / / n(c th Atr.e Name(Print) Current Mailing Address: LHH? -- _SEE ATTACHED DOCUMENT Telephone Signature 2.2 Authorized Agent: Green Collar, LLC 570 Newton St South Hadley, MA 01075 Name(Print) Current Mailing Address: 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 U 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) Check Number [� 7)`-/ This Section For Official Use Only ` ci -1gt1a— Date Building Permit Number: Issued: Signature: 7-zq 2dz i Building Commissioner/Inspector of Buildings Date 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 (:J YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0:4 X YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 0 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 ►j X 411 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 4 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [0 Siding[O] Other[®]X Brief Description of Pro_posed 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, I.I,C to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED DOCUMENT Signature of Owner Date ae r, ( c,\1 k\t-\ , 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. 'CoS l �tihr �h Print Name 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 08/23/2022 Address Expiration Date 8 Upper River Rd, South Hadley MA, 01075 Signature Telephone 413 532 1817 9.Registered Home Improvement Contractor: Not Applicable El Company Name Registration Number Green Collar, LLC 181415 Address Expiration Date 570 Newton St, South Hadley, MA 01075 Telephone 413 532 1817 03/31/2023 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 1$1 No Cl 11. — Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 Permit Authorization mass save Form save ertoriA oft' Site ID: 4296384 Customer: KAREN S DUNN Karen S Dunn , owner of the property located at: (Owner's Name,printed) 12 Lincoln Ave Northampton, MA 01060 (Property Street Address) (City) 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: Karen Dana Date: 08 / 24 /... 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 Fcr ffi=e Use Crl., 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: Ith(alr\ Awe The debris will be transported by: Gco�h C odor The debris will be received by: 6 r G4,►, c o I(q r Building permit number: Name of Permit Applicant (Cl l h oc,(r, Date Signature of Permit Applicant • M M. City of Northampton Massachusetts 6�, * r , '4)14; " x ° DEPARTMENT OF BUILDING INSPECTIONS 'S."; 212 Main Street • Municipal Building Northampton, MA 01060 SdW WT" MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: rlokh e Contractor Name: 6c0e►1 Co11ar- Address: JJP../Ach S} City, State: So cry ti \Nodt e7 "A Phone: Jf1� Spa— k 81-1 Property Owner Name: gar eh huhh Address: lI 10h(chh Ave City, State: No(-1 4Aneith MA (c4 1h,,, c h (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 of this affidavit. Contractor signature Date y//S/a I The Commonwealth of Massachusetts :..,. . ....�:. Department of Industrial Accidents 1 Office of Investigations A r ` _ ,` 600 Washington Street # _ Boston, MA 02111 •:,10+' 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 l,c 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. D 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 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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.® Otherinsulation/Weatherization comp. insurance required.] *My 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: I . 1 il^fr Ih Au e City/State/Zip:rUoOhc,A.Rlct', N4 o'oUo Attach a copy of the workers' compensation policy declaratii n page(showi nd 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: //13,AA 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#: . fier0/7 7- d10/ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, M ss�achusetts 02118 Home Improvempp"'tt c ntractor Registration .... Type: LLC f,4 .x ' __..4 ,,L, _. Registration: 181415 GREEN COLLAR LLC. ' i = "` W Expiration: 03/31/2023 570 NEWTON ST N . .. ; SOUTH HADLEY,MA 01075 -- p '. - Update Address and Return Card. SCA 1 0 20M-05/17 �q p K9an sna ALLoeca 6/.✓OI�aJJaesee eat Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only WE:LLC before the expiration date. If found return to: Registratloh Expiration Office of Consumer Affairs and Business Regulation o13I _ —--- 03/31/2023 • 1000 Washington Street Suite 710 I GREEN COLL Boston,MA 02118 o STEVEN ECKMA y /�°. 570 NEWTON ST`t�`vl 4 SOUTH HADLEY,MA'-W75 - Not valid without signature Undersecretary .cT p Commonwealth-of Massachusetts j Division of Professional Licensure . ! Board of Building Regulations and Standards C 0 ri stsiOlizAtkpfe,37isor ' CS-108817 . ' ires:08/23/2022 ' ' ROBERT CAtiNOU a JMs' f 8 UPPER RI1/IiR RD 1 s 1111IZ ,' ; . p : SOUTH HADLEY NIA i��;,!_," ". . O , Commissioner d,‘1. K. `YCuni..&;.. • • NWorker's Compensation and Employer's Liability Policy AmGUARD Insurance Company - A Stock Co. otGuARD Z!Berkshire Hathaway Policy Number R2WC182010 Insurance Renewal of R2WC053509 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: MAAHERIO 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