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118 SPRUCE HILL AVE BP-2017-1420 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-232 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-2017-1420 Project# JS-2017-002353 Est. Cost: $2572.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GREEN COLLAR LLC 108817 Lot Size(sq.ft.): 16030.08 Owner: FISCHER CALEB zonine: Applicant: GREEN COLLAR LLC AT: 118 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 7 WARNER ST (413) 532-1817 WC SOUTH HADLEYMA01075 ISSUED ON:6/7/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD 6" CELLULOSE TO 1068 SQ FT ATTIC 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 6/7/2017 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1420 APPLICANT/CONTACT PERSON GREEN COLLAR LLC ADDRESS/PHONE 7 WARNER ST SOUTH HADLEY (413)532-1817 PROPERTY LOCATION 118 SPRUCE HILL AVE MAP 29 PARCEL 232 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ).NCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TypeofConstruction: ADD 6" CELLULOSE 8 SQ FT ATTIC 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 INFO}tMATION PRESENTED: 1.."-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 Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management lie" tela I Sig rofB tiding •ftic 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 —�I( City of Northampton Status of Permit: 1 Building Department I Curb Cut/Driveway Permit � ti� i 212 Main Street Sewer/Septic Availability JUN _ 6 (i 1 Room 100 Water/Weil Availability 1\ it )Northampton, MA 01060 Two Sets of Structural Plans --pht�lle 413-587-1240 Fax 413-587-1272 Plot/Site Plans c`. '. _.. Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Add lre7ss: Tis section to be completed by office Map A- ot I I S5 press: c e 4,` ( ( Ave Zone LOvedayDis�� Unit Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �j 64le6 Yt Sckr I ( D 59(Qce fri(( Are- Name(Print) Current Mailing Address: ceE A4-4-E.t.(eEatom—en { elephone2 (0 — 3s-6 - 70 Y/ Signature 2.2 Authorized Agent: Green Collar, LLC 3 Main St.Unit B.South Hadley, MA 01075 Name(Pent) _ Current Mailing Address: 413 532 1817 Si.4 ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2- I-72_ (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection /,. 6. Total=(1 +2+3+4+5) 2/ S-72 Check Number /3q7 CA/0 This Section For Official Use Only Building Permit Number: Date Issued: 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 Building Department Lot Size Frontage Setbacks Front Side LL_ R:. L R: Rear Building Height Bldg.Square Footage ,o Open Space Footage (La area minus bldg&pavcd parkine) #of Parking Spaces Pill: _. . ._. (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW ©X YES O IF YES, date issued: IF YES Was the permit recorded at the Registry of Deeds? NO © 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 '4,4 X YES Q 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 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 filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO terr, 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 t l Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ID Siding ID] Other[m]X Brief Description of Proposed n / Work: INSULATION/WEATHERIZ.ATION co cee,/o S2 (a 68- jyfi, Z-&-f 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? L 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 Ownerr/9 �� y, Date I, 17-&-r/ ( Aft 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. C-CA n--q/� Print Name / W— c/aS -777 Signa e of 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 SignatureTelephone K413 532 1817 9.Registered Home 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 will 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(11 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 perforin 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 mber: Name of Per it A pplican Date Signature of Permit Applicant Permit Authorization g„r mass a Form a g Sriptt mmq,s1 orib.. rnRttCIPrtrm tet.. Site ID: 50288824 Customer: Caleb Fischer • 1, Caleb Fischer ,owner of the property located at: (Owner's Name,minted) 118 Spruce Hill Ave Florence (Property Street Address) lClty) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work onproperty. : 7Cm Owner'r's Signature: • Date: 3/a-0 7 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 4-turf � 6i� 57zrl2-Df- Participating Contractor Date o •o CLEAResult • 50Wasfiington Street,Suite 3080 • Westborough,MA 01581 • 1800480.1472 Q For Office Use Only Rev.102015 The Commonwealth of Massachusetts rm, Department of Industrial Accidents Office of Investigations =. 600 Washington Street a,:.mm,/ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businss/Organizationilndividual): 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): 1.E. I am a employer with I 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2.LI f am a sole proprietor or partner- ship and have no employees These sub-contractors have S. ❑ 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.❑ 1 am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, 81(4),and we have no employees. [No workers' 13.® Othednsulation/Weatherizatmn comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicaling 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 employeesif 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_Berkshire Hathaway Guard Insurance Company Policy#or Self-ins. Lie. #: R2WC727792 Expiration Date: 9/23/2017 Job Site Address: If �j CeircCt fj;-(( At,. City/State/Zip: Pt,Doge t NA 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 r . penalties of perjury that the information provided-rareabove is true and correct. Si nature: �+ Date: J f Zr7,'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 S. Plumbing Inspector 6.Other Contact Person: Phone#: 114 Worker's Compensation and Employer's Liability Policy `4erksh I re Hathaway AmGUARD Insurance Company -A Stock Co. Insurance Policy Number R2WC727792 sillG UARD Companies Renew IYCCI 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 Agency Code: MATIER10 5 Federal Employer's ID 47-1041086 Insured is limitedLiabilityI C act � �,J (2) Polley Period 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-WC2003066 D. This policy includes these endorsements and schedules: I` 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 an another page) ! Total Estimated Policy Premium $ 5,749 Total Surcharges/Assessments $ 299.00 Total Estimated Cost $ 61048.00 OUTPOST USL_ Xx Page- 1 - Information Page MGA :R7WC727792 WC 00000IA Date :09/14/2016 MANOTE Issuing Office: P.O.Box A-H, 16 S. River Streetr Wilkes-Barre, PA 18703-0020 •www.guard.com Massachusetts Department Of pup is nd of pr Board of Building Regulations and Stantlarards.' License CS 108817 ^ ROBERT CALHOUN 390 NEWTON ST SOUTH HADLEY MA 91973 N-71_An CAS Commissioner 08/23/2018 cYAe %ri n/fcn/wea/ c C—iLTwacAia:er ,.' 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. -s'1 CJ - 0 Address O Renewal ❑ Employment O Lost 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 03/31/2019 10 Park Plaza-Suite 5170 GREEN COLLAR LLC. Boston,MA 02116 STEVEN ECKMAN 3 MAIN ST.UNIT B. SOUTH HADLEY,MA 01075 UndersecretaryNot valid without signature