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29-270 (5) 57 LONGVIEW DR BP-2021-1532 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-270 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-2021-1532 Project# JS-2021-002546 Est.Cost: $4957.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(sq. ft.): 15333.12 Owner: KUZMESKI 2009 IRREVOCABLE TRUST Zoning: Applicant: GREEN COLLAR LLC AT: 57 LONGVIEW DR Applicant Address: Phone: Insurance: 351 NEWTON ST (413) 532-1417 WC SOUTH HADLEYMA01075 ISSUED ON:6/24/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION 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. 5 Certificate of Occupancy si#;narnre: � . 1� . FeeType: Date Paid: Amount: Building 6/24/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northamp on c�,Status of Permit: Building Department �;Curb Cut/Driveway Permit 212 Main Street'16'4F 2 -Sewer/Septic Availability Room,10Q `� ater/Well Availability Northampton, MA-0060 (V(9/ Two Sets of Structural Plans phone 413-587-1240 Fax 413-5& 72 Plot/Site Plans pF.r��ti� 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 Map Lot 2 701 Unit C.c.t)t'1 o‘ vJ 11 Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /Vlaf� /UZMrS4I S-7 1-014ur'Qv/ /Dr Name(Print) Current Mailing Address: SEE ATTACHED DOCUMENT Telephone SaFd 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 S 1 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee //� 4. Mechanical(HVAC) l/� 5. Fire Protection 6. Total=(1 +2+3+4+5) a.51 Check Number l.'0°1 q This Section For Official Use Only !! g�-2/"/5 3Z Date Building Permit Number: Issued: /0 .7c) Signature: _ _ _ 1 Building Commissioner/Inspector of Buildings Date Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be tilled 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 O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW igX YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO 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 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 0 NO ►vi 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 Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [DI Other[(SOX Brief Description of Proposed 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, LLC to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED DOCUMENT Signature of Owner Date Co ikd:,Y1 ,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. Copt1 oL,x-1 Print Name /� �� ‘,;'f/(di? Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: CS-108817 Robert Calhoun License Number 08/23/2022 Address Expiration Date 8 Upper River Rd, South Hadley MA,01075 Signature Telephone 413 532 1817 9.Renistered Home Improvement Contractor: Not Applicable ❑ 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 W No 0 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 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 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: Si Lc ) Dr The debris will be transported by: (. r. b, Colic. r The debris will be received by: ly l r;d©,, t. S�j �� +� '• / atc7S" Building permit number: Name of Permit Applicant Co.l►,,,u r, c 6A,/al b ' ,,� Date Signature of Permit Applicant GGREE COLLAR Permit Authorization Form I, /41c (/ / /h8<, ; l (Owner's Name) Owner of the property located at: S7 C_vhcy„,',9.) Or (Property Address) (Property Address) Here by authorize Green Collar, a certified Mass Save Independent Insulation Contractor, to act on my behalf to obtain a building permit and to perform work on my property. -4(ainig — (Owner's Signature) (Date) 351 Newton St. Unit B South Hadley,MA 01075 Phone:413.532. 1817 Email: support@greencollarma.com The Commonwealth of Massachusetts ��"„" Department of Industrial Accidents rtidli="? Office of Investigations Ai 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: 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 15 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.El 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' [No workers' comp. insurance comp. insurance., 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.El 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.] *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. *'Contractors 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: Si t anyV rest) orCity/State/Zip: riceph�.P, AA4 (3ia,); 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 certif under the pains and penalties of perjury that the information provided above is true and correct. Signature: P-Ifec Date: 61/d/a 1 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#: rr-- --- Commonwealth of Massachusetts .121 Division of Professional Licensure Board of Building Regulations and Standards ! , k i , Construction Supervisor CS - 108817 , , ires : 08/23/2022 ROBERT CALHOUN -,..., , . 8 UPPER RIVER RD 4 ,td MON, Nemo* SOUTH HADLEY MA 01076 ..e...* , -0•0 , ,L. a Commissioner la,, K. bl&ridia._.,. IL . Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 181415 GREEN COLLAR LLC. Expiration: 03/31/2023 570 NEWTON ST SOUTH HADLEY, MA 01075 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 181415 03/31/2023 1000 Washington Street -Suite 710 GREEN COLLAR LLC. Boston,MA 02118 STEVEN ECKMAN 570 NEWTON ST _c(4eirti°(&(a.G>!r SOUTH HADLEY, MA 01075 Not valid without signature Undersecretary e Worker's Compensation and Employer's Liability Policy AmGUARD Insurance Company - A Stock Co. 4lBerkshire Hathaway Policy Number R2WC182010 r44 GUARD Insurance Renewal of R2WC053509 �•A 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: MAAHER10 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 [3JA. 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 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