23D-174 30 BAKER HILL RD BP-2017-1493
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 174 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-1493
Project# JS-2017-002489
Est.Cost: $3487.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 13155.12 Owner: GUZOWSKI RICHARD
Zoning: URB(I00)/ Applicant: GREEN COLLAR LLC
AT: 30 BAKER HILL RD
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:6/23/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 11 INCHES OF CELLULOSE TO ATTIC FLAT
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 6/23/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-1493
APPLICANT/CONTACT PERSON GREEN COLLAR LLC
ADDRESS/PHONE 3 MAIN ST UNIT B SOUTH HADLEY (413)532-1817
PROPERTY LOCATION 30 BAKER HILL RD
MAP 23D PARCEL 174 001 ZONE URB(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 0�('
Building Permit Filled out
Fee Paid
Typeof Construction: ADD 11 INCHES OF CELLULOSE TO ATTIC FLAT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108817
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
FINF9RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Pennit from Conservation Commission Permit from CB Architecture Committee
Pert from Elm Street Commission Permit DPW Storm Water Management
Signature of Bu ding Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Department use only
City of Northampton Status of Permit:
r I Building Department Curb Cut/Diiveway Permit
JOA) o 212 Main Street Sewer/Septic Availability
2 2 Room 100 Water/Yee!!Availability
i 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
1.1 Property Address: This section to be completed by office
Map
ot
O - ked 1 1 1 l(
Zone 4. 191 LOvedaY%Is Unit
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
kic (-id Cu t cc.;_S k c ' o eco kec' NL( ( g d
Name(Print) Current
/�-/-�-/�,, ^ {/�1�' �}- Current Mailing Address: ,//? -.77e/
56.6 47 /'TL!,/ acuM�-V`/ Telephone
Signature
2.2 Authorized Agent:
Green Collar, ITC 3 Main St. Unit B. South Hadley, MA 01075
Name(Print) __ Current Mailing Address.
413 532 1817
sign. . Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (771 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Firen from(6)
vg
6. Total =(1 +2+3 +4+5) y 8' 7 Check Number ,c,/aQ
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:Signature:
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 he filled in by
linilding Department
Lot Size
Frontage
Setbacks Front
Side L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage °o
(L,arca minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Lsanon;
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW OX YES 0
IF VES, 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 DONT KNOW gX 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 140 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,�ex5cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO co 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 n Addition ❑ Replacement Windows Alteration(s) l l Roofing n
Or Doors [I
Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [q Siding[0] Other[I4X
Brief Description of Proposed �V7 // /
work. INSULATION/WEATHERINATION .i- Z (1 C'f 657t yd /055 t9 ,4 & -F7'
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
sa.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
I. 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
I, 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
Signature of Owner/1) ,�p� Date
o
r�l'� �'(C/�'C.O/1 ,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.
$ 4-C-C z Pekin
Print Name
22 /7
Signatu =/-Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder CS-108817
Robert Calhoun License Number
8/23/2018
Address Expiration Date
390 Newton St. South Hadley, MA 01075
Signature Telephone
413 532 1817
•
9.Reolstered CHome'Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
3 Main St Unit B. South Hadley, MA 01075Telephone 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 N No ❑
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.CM R 780, Sixth Edition Section 1083.5.1.
Definition of homeowner: Person(s)who own a parcel of land on which heishe 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)ofthc Massachusetts General Laws Annotated,you may be liable for persons)
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 Stale 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:
The debris will be transported by:
The debris will be received by:
A ,
Building permit number:
Name of Permit Applicant/,
Date Signature of Permit Applicant
RISE60 Shawmut Road, Unit 21 Canton,MA 02021 1 339-502.6335
ENGINEERING- www.RlSEengineering.com
OWNER AUTHORIZATION FORM
Denise Ankudowish
(Owners Name)
owner of the property located at:
30 Baker Hill Rd
(Property Address)
Florence MA 01062
(Property Address)
hereby authorize (9"rOoT r� l��
(Subcontractor)
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.
Owner's Signature
5 , 11
Date
'li
'1 11
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
:' 7.$ Boston, MA 02111
v
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: 3 Main 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):
.® I am a employer with 4. ❑ I am a general contractor and 1
employees (full and/or part-time).* have hired the sub-contractors I 6. 10 New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingany g for mc in capacity. employees and have workers'
Y 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 ant a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required] * c. 152, §I(4),and we have no
employees. [No workers 13.1X Othednsulation/Weatherization
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their worker'compensation policy information.
s Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new anidacit indicating such.
:Contractor 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'comppolicy 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: Berkshire Hathaway Guard Insurance Company
Policy k or Self-ins. Lie.#: R2WC727792
Expiration Date:: 9/23/20171
Job Site Address: J O J Kee' tilt( Imo` City/State/Zip: f l- t t
o( ce7 _sc,
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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. . • e t aft .d penalties of perjury that the information provided above is true and correct.
Si'nature: Date: dr7er /7
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#:
•
A Worker's Compensation and Employer's Liability Policy,
,K
Berkshire AmGUARD Insurance Company - A Stock Co.Berkshire Hathaway
GUARD A RD Policy Number R2WC727792
Companies Renewal of R2WC652666
NCCI No. [21873]
Policy information Page (AR)
(1)Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
3 Main St. Unit B. 16 NORTH ELM ST
SOUTH HADLEY, MA 01075 Westfield, MA 01085 f
(/Yq I
Agency Code: MATIERSO
Federal Employers ID 47-1041086 Insured is Limited Dailty1C LLC)
11(0-11>7
[2] Policy Period 1 F
From September 23, 2016 to September 23, 2017, 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 $ 5,749
Total Surcharges/Assessments $ 299.00
Total Estimated Cost $ 6,048.00
INTERNAL USE Na Page - 1 - Information Page
MGA : R2WC27792 WC 000001A
Date 09/14/2016
MANOTE
Issuing Office:P.O.Box A-M,16 5.River Street,Wilkes-Sarre,PA 18703-0020 •www.guard.com
plif -'.assachusetts Department or Pdnuc Sate `
Board of Building Regulations and Standards
License CS-1118817 • a"
ROBERT CALHOUN - #
300 NEWTON ST -
SOUTH HADLEY MA 011'15 .
M1.—v. l -- Exp,
Commissioner 08/232018
a.
a\ _ cl/if (CLdmmmiirciewe 44, c/2c ' cfioacAu eJe/
1 Ar
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Registration: 181415
3 MAIN ST.UNIT B. Expiration: 03/31/2019
SOUTH HADLEY,MA 01075
• Update Address and return card. Mark reason for change.
0 Address 0 Renewal 0 Employment 0 Lost Card
Office of Consumer Aaalrs 5 Susumu Regulation
1111t14-. HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Rad4trabon Expiration Office of Consumer Affairs and Business Regulation
181415 03131(2019 10 Park Plaza-Suite5170
GREEN COLLAR LLC. Roston.MA 02116
STEVENECKMANPL'4.x---
SMAIN
T.UNIT
S U
SOUTH HADLEY.
Su 01075 Undersecretary Not valid without signature