24D-323 (6) i
155 PROSPECT ST BP-2020-0800
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-323 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-2020-0800
Proiect# JS-2020-001386
Est.Cost: $3071.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sg.ft.): 4443.12 Owner: OSORIO RUIZ EVER
Zoning URC(100) Applicant. GREEN COLLAR LLC
AT. 155 PROSPECT ST
Applicant Address: Phone: Insurance:
390 NEWTON ST 413 532-1817 WC
SOUTH HADLEYMAO 075 ISSUED ON.1/14/2020 0:00:00
TO PERFORM T FOLLOWIN WORK:INSULATE BASEMENT CEILING
POST THIS CARD SO T IS VISIBLE FROM THE STREET
Inspector of Plomhing nspector of Wiring D.P.W. Building Inspector
Underground: ervice: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
G s: Fire Department Fireplace/Chimney:
R ugh: 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 Sip-nature:
FeeType: Date Paid: Amount:
Building 1/14/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Y
Dep
-----:-�-.. City of Northampto
a` Building Department O
212 Main Street SULATION
1 f Room 100 J
�a ' Northampton, , 060
ONLY
��
phone 413-587-1240 F9�, -1272
In�SP
r,--
APPLICATION FOR INSULATION FOR A ONE OR TWOF T DWEL NG ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
This section to be completed by office
1.1 Property Address: 2
Map Lot Unit
G
Zone Overlay District
O WN'
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Maj(4ng�AdCdlress:, _ 9 3C) l
to
Telephone
Signature
2.2 Authorized A ent:
(' re n Co\ LLCp-
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ( L;� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee /Q
4. Mechanical(HVAC) v
5. Fire Protection ^�
6. Total=(1 +2+3+4 + 5) Z Check Number v
This Section For Official Use Only
"" �!�
Building Permit Number: V DateIssued.
Signature: _
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
I
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /► Not Applicable ❑
Name of License Holder: -lJ I
License Number
3qC, WcL�- �Act& V I a C, ?, r
Address Expirati n Date
g1�i � 32 - q
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑ 1 ?1 "" (6
8YkL) ✓t \
Company Name Registration Number
Address Expiration Cate ? �1
�IA rlQ l�� (1� Telephone`T)3 -32
SECTION 5-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...... ❑
Brief Description of Proposed Work NO INSULATION ONLY
�
C7 rtcn C' l a v-! Las 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.
IC nlJ
Print Name
1�(0 �O
Signature of Owner/Agent Date
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
•
Massachusetts
A'
* f DEPARTMENT OF BUILDING INSPECTIONS
r 212 Main Street • Municipal Building p OC
Northampton, MA 01060 3h�^
MANDATORY FOR HOUSES BLUIL T BEFORE 1945
Property Address: L �l�®� Cit L'� QST,
Nameactor l, , r4 u�l L L
Address: 3S ( N, P IA,Ut Vi
City, State: m �Ca C ii.'V ;
Phone: 41�) J 7J L 1 1 9
Property Owner �
Name: � Q�
11'y f-�y a
Address: Pf a
City, State:
I, _(—7r�i_h C� G�� L l� (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 23
City of Northampton
/ •''' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
Northampton, MA 01060 rsY�y `�o
Debris 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.
The debris from construction work being performed at:
1Y3 V Q1 C* S'kf
(Please print house number and street name)
Is to be disposed of at:
o f 2+ 3 Ctu c OR-P. , tk,
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(�\r-UA 'LW cd U LL
(Company Name and Address) d'
- 6 ;:Zd
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
i
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS y �°
212 Main Street • Municipal Building J PD
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: TQ,ID h i *-U Est.Cost: , l�
Address of Work: S P✓0 Sa (/� 6�y e t
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
l c� 2 ' Gi-e-en C
e HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Datc Owner Name and Signature
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Ever Osorio Ruiz
(Owner's Name)
owner of the property located at:
155 Prospect Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize C UA l U\V
(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'—sS4ignatu
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 02021 1339-502-6335
www.RISEengineering.com
enc a,vsnnsanrm""n m, 1.aw"w&isaac"w
Dgwuftent of Industrial Accidents
0 ,fuM of Investigations
600 Washington Shed
Boston,MA 02111
www.wamgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumber s
Abubcaut Information Please Printb _
Name M=nc" =mJwxhW): Green Collar LLC
Address: 35I--Nowton St. Unit B
Ci /StIWZi : SouthHadi ,iVIA 01075 Phone M 413 532 1817
Are you auzzq*yw9. Cheek the appropriate box: Type of project(required):
4. ❑ I am a general contractor and I
1.® I am a employer with,_� 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 amw1wd sheet 7. Remodeling
ship and havt no,employees Tbrese. have 8. ❑Demolition
workingfor me in an employees and have workers' 9 building addition
[No workers'comp.insurance _ comp'insamIIce.1or additions
Wired.] 5. We are a corporation and its -10.[]Electrical repairs
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.❑ Rootrepairs
insurance repired.]t c. 152,§1(4),and we have no
employees.[No workers' 13•®Oth�nsulation/Weathtrization
cemP insuuance requir+ed.]
*Any qp icag to drab boa#1 nun abo M out the wc.dm bdow showing their worbea'migimatim pohry infosma6dn.
t Homwwnaa who submit this&Mdavit they are doing all wait and then hire outside eonauton must submit a new affidavit es
es havve
suck
tCdotnetdss�check this box must a0whed m additional abed showing the name of the sub-0000a�ms and since whether OF not those entiti
aMkipm if do sub-conusc ora bwve empl*mm tbcy must PmvWc their wad='come•policy mw bw
I rur a ewpila w dart is proW&V wwkers'comparsaaioa bLwr arae for myempkj em Bdow n dwpoft endjob site
a�
Instmince Cody Name: AmGUARD Insurance Company-A Stan Co.
Policy#or Self-ins.Lic.#. R2WC053509 Expiranon mate: 9/2312020
� o r -e C : M (2LLJ_flXJob site Address: eZ
Annals a copy of the wratess'eompengthn policy declaration page(showing the policy number and expiration date).
Faihme to secure coverage as required ander 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-yaw 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 IYm by aero*ander thepdsts andperseflfies ojperlisrp cwt die inforwed x provided above is Owe Nd torrent
SitmsmrE- �A Date.• c)
Phone#. 413 5321817
orwW use ox#L Do ow wd &is dire.apea,w be coxygded by coy or town of'iciat
City or Town: Perri tucense#
Issuing Authority(drde ere): '
Plamtiing Inspector
1.Bosrd if HaM 2.Building Deepartment 3.City/Tom m Cksrk 4.Ekctricd Inspector S.
6.Other
Contact Persson' Phone#•
Worker's Compensation and Emdot er's Llabigty WIr
Berkshire HathawayAm6UARD�urnrum Company-A Stock Ca
InsurancPWky Number R2 05350!
of
G U A R D � aNCCCT No. E-216873
PoUL►Lnfannatbn Page(AR)
[i]NM >� and Mailing Addre i Agency
1 351GRLC Newton St Uri B TIERNEY INSURANCE AGENCY, INC.
f0uth Hadley,MA 01075-2351 PO
Box Iso
Westlield, MA 01085
Agency Code: MATIER10
Federal Eni
plover's ID 47-1041086 Insured Is limited Liability Co. (USC)
Risk ID Number 1038965 ,
s
[Z] Polk
From 23, 2019 to September 23, 2020, 12:01 AM,standard time at the Insured's mailing
address.
[3] Coverage
k
A. WorkaW Compensation Insurance- Part One of this policy applies to the Workers'Compensation
Law of the bffi%Ang states: Manachuwas
8, Employer's Uabpity Insurance- Part Two of this polky applies to work In each of the states Hsted
In Item[3]A. The limits of our liability under Part Two are:
6WHY wry by Accident-each accident $500,000
BOCINY Bbdury by Okease_each empbM $500,000
odi '
IY Injury by Dismse policy Omit ;5001000
C. Refer to Residual Market united Other States Insurance Endorsement-WC2003068
D. This polk�j Includes these endorsements and sdreduks:
See bertslon of Information
Page-Schedule of Forms .
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
tlorts,Rates,-and Rating Plans. AMI required informa
aulut. (Corrtlrwed on another pie) tion is subject to verification and change by
ETom
bd IroNcy ft"dom OFAmemmMits "MOD
Coattt� a
MOA : Page-1 - IrNbrr otbn Pape
Dib M/ WC 000001A
HAMM
Zawrine Olrmm P-O.Bou A-14,39 PubOe S*mv,WIm-aarrer,PA la703_0020 0 www4uardAm
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COUM LLC. RVsbvMw: 181415
951 NEWTON ST UNIT B ExMtrM kx : 08131!1011
SOUTH HADLEY,MA 01075
CAI o taraen7
Updtlt Addy ted RNun Card.
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NOME■APRWENEAfr CONfRACTdt IbSiMrrioe v0dfor 4donly
TVM LLc , -b dale. w Oawd plum fa
zm000 0Mwo d Cwraraew Aft"and&wkv s Rsoubdm
GREEN is" 03131=1 1Wieddlighm Sked-s;uft 710
Botbmti AAA 02110
STEVEN -
361 NEWTON ST Mr Al
SOUTH HADLEY,MA 01075 _ � Y- NOt vdid without signature
D1Wdw of Proftsek"Lkq§w"
Bond of OuildhV ftguldioes and Sfarrdwdt
Conetr www Supervisor
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