17C-170 (4) 34 HIGH ST BP-2018-1129
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV-.Block: 17C- 170 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND
D(
FY�UND (MGL
Lcc.142A)
Categmv: INSULATION BUILDING 1 ERMIT
Permit# BP-2018-1129
Proiect# JS-2018-002031
Est.Cost: $2680.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sa.R.): 14069.85 Owner: SURGEN PAUL C&LOTTIE B
Zonine:URB(100)/ Applicant. GREEN COLLAR LLC
AT: 34 HIGH ST
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:5/1/2018 0:00:00
TO PERFORM THE FOLLOWING WORIGADD 10" CELLULOSE TO 818 SQ FT ATTIC
FLOOR
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: O_ 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:
FeeTvpe: Date Paid: Amount:
Building 5/1/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
— _ _ Deparbranl Useorrryr
Ci of Northampton Status of Peanut
Buil ing Department Curb CutlDrlw>villyPearat
QPw 8 2 Main Street Sewerilli
Room 100 WeterlWolS AweNetiiIXy
DEaro ,,8FFCTiNortha pton, MAO106O Two Sells orSW)Gbo*Plare
No. - " -1240 Fax413-587-1272 plbNsfie Plans
Ogler Spadfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION 6,919 - iia 9
1.1 Property Address: This
This section to be completed by office
Map
ot 170
3 q ( V l 20 LOverlay District Unh
Elm SL District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: <
aLfl //>�rS
Name(Pnnt) Current Mailing Addragg
(/''� nc:!cii+r�jt�f-- ��3-say-s.��
Si nal.,. .�y Telephone
Signature
2.2 Authorized Agent:
Green Collar,LLC 3 Main St. Unit B.South Hadley, MA 01075
Name(Pent) Cement Mailing Address:
413 532 1817
Signaterif Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermitapplicant
1. Bending /' �G (a)Building Permit Fee
2. Electrical LO (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) �J
5. Fire Protection pp
6. Total=(1 +2+3+4+5) p® Check Number o)d
This Section For Official Use Only
Date
Building Permit Number: Issued'
Signature:
Building C ssicnedlnspector of Buildings Data
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m 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
(Int area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&tncation
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#.
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW OX 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 filing)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO (K 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 Fi lteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[C3] Other[MX
Brief Descrip2tion of Proyyosed `��r�l/ � S� / elf
e�
Work: INJULAT reusedN/WEATHERIZATION — ( v fo O � cF�ty–
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes XNo
Plans Attached Roll -Sheet
ea.if New house and or addition to existing housing. cornolete 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 stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
L 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
1, 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� Data
I, 5/ L l'e� ��' ��� 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.
5�'Ie4- e,q
Print Name —
Signat Own Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder'. CS-108817
License Number
Robert Calhoun
8/23/2018
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signature l.� Telephone
413 532 1817
9.Renish red Home hnoroarement Contractor: Not Applicable D
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 will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... W No...... D
11. - Home Owner Exemption
The current exemption for`homeowners"was extended to include Owner-occupied Dwellings of one(1) or lwo(2)families
and to allow such homeowner to engage an individual for hire who dues 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 whoo trcts more than one home in a mo-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 far 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 ofthe work for which this peril 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
RISE60 Shawmut Road, Unit 2 Canton, MA 02021
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Paul Surgen
__. (Owners Name)
owner of the property located at:
34 High Street
(Street)
Florence, MA 01062
(Town, State, Zip)
hereby authorize-6086
(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 homeowner's
responsibility to close out this permit by contacting their municipality at the cc p etion of this work.
-Customer Signature
( — ( 4— (
-Sign Date
1/19/2018
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: /V7i / f�
The debris will be transported by: ZVllq � A'71 js
The debris will be received by: ///�
Building permit number:
Name of Permit Applicant
yIZ-'-)L9
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
wi 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):
LM I am a employer with 6— 4. ❑ I am a general contractor and I 6. ❑ 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
workingfor mein an capacity. employees and have workers'
Y P tY 9. E] Building addition
req workers' comp. insurance comp. a corporation
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.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t a 152, §1(4), and we have no
employees. [No workers' 13.[M Othednsulation/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.
tCuntractors 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 subcontractors 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. Lie.
4: J R2WC88555214 Expiration Date: 9/23/2018
Job Site Address: J / l j' �7 City/State/Zip:
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 certify under the pains and penaldes of perjury that the information provided above its true and correct
Sinnatu e, t Date: 101 -2 D
/
Phone#: 3 532 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#:
Worker's Compensation and Emnlover's Liability Policy
Berkshire Hathaway AmGUARD Insurance Company-AStock Co.
Y Polley Number R2WCSSS214
Insurance G U A R DCompanles NCCI No 1[2187of 31
Policy Information Page(AR)
[I]Named Insured and Mailing Address Agency L6AfGCSV
GREEN COUAR LLC TIERNEY INSURANCE AGENCY,INC.
3 MAIN STREET UNIT a 16 NORTH ELM ST
SWIM HADLEY,MA 01075 Westfield,MA 01085
Agency Code: MATIER10
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 Insured's mailing
address.
[31 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 Erdnrsement-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 ver0iNation and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 13,325
Total Surcharges/Auassments $' 584.00
Total Estimated Cost 13 909.00
IBgBNEL VSE__QH Pape-1 - Intormsom Page
MGA :R2WC855214 WC 000003A
Data :10/022017
KMOTE
Issuing Office:P.O.Box A-H, 16 S.River Street,Wilkes-Barte,PA 18703-0020 a www.9wrd.com
Mmsachuserts Department of PJDIIC Sate[:
Board of Building Regulations and Stand&
License:CS-108817
ROBERT CALHOIaI
O N 8T
SOUTH TX HADLEY 6M8'076
1,J-N CA_ Ex,-,,
Commissioner 061231201
'" 'G�ie tC�am,�xa7rcUecc�lfi a�C�lrac�ucaeC�
4
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: 03/31r2019
SOUTH HADLEY.MA 01075
IIPdMe Address and!return send Mark reason lar CBalgw
K., o muss„ 0 Address 0 RsnmW 0 Eavlownent O Lost Card
Onke at Cowmwr Aaek s A eu W eas Regulasnn
HOME IYP110YEMENT CONTRACTOR Registration valkl Nr lndM4d us,arty
_ TYPE:LLC blft* MapM dp 8faurW rNYrrl b:
nownwom rum OMa of Censurer AlbksrW Business Regulation
181415 03131/2010 10Prk Plea-Su1M6170
-GREEN COLLAR LLC. Boson,YA 02116
STEVEN ECIOAAN
3 MAIN ST.UNIT B.
SOUTH HADLEY.MA 010]5 Undweecrewy Not Valid 1Yhhout signature
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