17D-074 (9) 16 GARFIELD AVE BP-2018-1062
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-074 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catee rv' INSULATION BUILDING PERMIT
Permit BP-2018-1062
Project# JS-2018-001917
Est.Cost: 52184.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor., License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sp. ft.): 13460.04 Owner: MCCUSKER KATHERINE
zoning: URB(100)/ Applicant: MCCUSKER KATHERINE
AT. 16 GARFIELD AVE
Applicant Address: Phone: Insurance:
16 GARFIELD AVE (413) 230-7733 O WC
FLORENCEMA01062 ISSUED ON:4/20/2018 0:00:00
TO PERFORM THE FOLLOWING WORKADD DENSE PAK CELLULOSE TO 1120 SQ FT
WALLS
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 4/20/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
MR 1 ? s f l �Gt ff0yt�
Pr w= �i 1011 ti oepermbar use only
�4 W31ton Slewa of pemoh
Building Department Curb CutOrivexsyy..Period
212 Main Street SeweN9el AvaIIal ify
Room 100 Waterlwe6'AvailabSty
Northampton, MA 01060 Tise Sam of Structural Poen.
phone 413-587-1240 Fax 413-587-1272 Plot/SRe'plelq
Other SpapfY
APPLICATION TO CONSTRUCT,ALTER REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO
ry FAMILY DWELLING
SECTION t -SITE INFORMATION 6j - j D— t V 0,X
1.1 Property Address: '-this section to be completed by office Map ( 1 % Lot '7C/ nit
Unit
U
Zone Charley District
Elm St panic ce Chariot
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Gyfe M «tlsktf 1� ��f � i� AV
Name(Print) Curren,MailgPtltlre�s:��_
)G� Cr' �a Gr.`CL //6EG/H2n� TelePho� JJ LL
Signature
2.2 Authorized Agent:
Green Collar, LLC 3 Main St.Unit B. South Hadley, MA 01075
Name(Pont) Current Mailing Address:
413 532 1817
Sign.kae Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by ermitapplicant
1. Building , ( moi-(� (a)Building Permit Fee
2. Electrical o (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total= (1 +2.3+q+5) Check Number
This Section For Official Use Only
Building Permit Num r: Dale
Issued:
r
Signal20 /Zr
i
Building Commi oner/Inspsctor of Buildings nate
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 °o
Open Space Footage
(Lot area minus bldg&paved
parking)
4 ofliarking 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 H
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW g)X YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Dale 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(Gearing,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 ANeration)s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs )O] Decks Iq Siding 101 Other I®jX
Brief Descri22tion of Proyposed ,,//��
Work: INSULATION/WEATHERIZATION Ack ag SG klc ee&l ere
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement _Yes XNo
Plans Attached Roll -Sheet
Be.If New house and or addition to existing housing, complete the following:
a. Use of building :One Famili Two Family Other
It. Number of rooms in each family unit: Number of Bathrooms
-
a Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of healing? Fireplaces or W oodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. 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_ Privatewell_ Citywater 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 y /�.� ` Date
I, l !"`-'�� � km-a\ ,as Owner/Authorized
Agent hereby that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the spains
and penalties
—off perjury.
Print Name
rf jd
Signature erogen Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun
8/23/2018
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signature ^ Telephone
413532 1817
8.Repletared Rome Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
3 Main 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 volt result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... W 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 buildine 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 Heath)of the Massachusetts General laws Annotated, ,on 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 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:
The debris will be transported by
The debris will be received by:
Building permit number:
Name of Permit Appli nt
Date Signature of Permit Applicant
Columbia Gas
of Massachusetts 60 Shawmut Road, Unit 2 Canton, MA 02021
A elBauru CwryM.ny
OWNER AUTHORIZATION FORM
i, Katherine Mccusker ,
(Owner's Name)
owner of the property located at:
16 Garfield Avenue
(Street)
Florence, MA 01062
(Town, State, Zip)
hereby authorize
(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.
The Permit will be secured by the insulation contractor, at no additional cost. It Is the homeowners
responsibility to close out this permit by contacting their municipality at the completion of this work.
-Customer Signature S
-Sign Date
3/21/2018
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: 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):
L® 1 am a employer with_(:�� 4. ❑ I am a general contractor and I 6. E] New construction(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
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insumnce3
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.L] 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.® Othednsulation/Weatherization
comp, insurance required.]
'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
I 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-contraeters and state whether or not those entities have
employees. Ifthe sub-connuelm,have employees,they must provide their workerscomp.policy...her.
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. Lie.#: R2WC855214�^ ,} Expiration Date: Iry—'eA 9/23/20118,
Job Site Address: /(D _ U /'i'L- City/State/Zip:" , 't
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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the its and pearl s of perjury that the information provided above
is nue and correct
Sismatum It Date
�0 r
Phone#: 3 532 1817
Official use only. Do not write in this area, to be completed by city or town oJjrciat
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Worker's Compensation and Employer's Lubin@$Policy
Al
rkshire Hathaway Am6UARD Insurance Company-AStock Co.
y Policy Number R2WC855214
UARDInsurance Renewal of NEW
Companies NCCI No. [218731
Policy Information Page(AR) )01' V
[1]Named Insured and Mailing Address Agency
GREEN CDUAR LLC TIERNEY INSURANCE AGENCY,INC.
3 MAIN STREET UNIT B 16 NORTH ELM ST
SOUTH HADLEY,MA 01073 Wastii id, MA 01085
Agency Code: MATIERIO
Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC)
[2] Policy Period
From September 23,2017 to September 23,2018, 12:01 AM,standard time at the Insmed'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
e. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed
in Rem(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-WC2003068
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
audlt. (Continued on another page)
Total Estimated Policy Premium $ 13,325
Total Surcharges/Assessments $ 584.00
Total Estimated Cost 13 909.00
ItIffBNAL USF.—ger Page-1 - Information Page
M6A :R2WOSS214 WC 000001A
Pate :1010212017
puvrom
Issuing Office:P.O.Box A-H, 16 S.River Street,Wilkes-carte,PA 18703.0020 a www.guare.com
Massachusetts Department or Puoi c Satet,:
Board of Building Regulations and stantla
License.CS-108817
:,ors'•.:-:• - �:.._.. .
RDBIAIT CALHOUN
380 NEWTON ST
SOUTH HADLEY MA 01676
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Commissioner 88=2010
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Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. RegWrS00m 181415
3 MAN ST.UNIT B. E)OratirM 03/31/2019
SOUTH HADLEY,MA 01075
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