44-134 (6) 1006 FLORENCE RD BP-2018-1249
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:44- 134 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-2018-1249
Proiect# JS-2018-002223
Est Cost $1539.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groutr GREEN COLLAR LLC 108817
Lot Size(sa ft,): 130897.60 Owner: AKERS ALYX
tonin : Applicant: GREEN COLLAR LLC
AT. 1006 FLORENCE RD
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.•5124120180:00:00
TO PERFORM THE FOLLOWING WORK.ADD 2" RIDGID BOARD TO RIM JOIST 80,
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/Cbimney:
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 Sienature:
FeeTyoe: Date Paid: Amount:
Building 5/24/2018 0:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
S�, Ia fi on
RECE� City f Northampton 8btusPP� t�
uil ng Department CDtt1 ClAttichenny'Pertg4
MAY 2 3 2018 21 Main Street
Dom 100 WaterlWrigi '
sP he pion, MA 01060 TWOal Bbur�xafPbeu �. _ � •. •� G.,, '
DEPT.OF BOIL0111fi1f1p� - 8 - 240 Fax 413-587-1272 PWUSite Rene
NOPTHAMr'TO� ^"^
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PropertyAddres "� (Th�,{is section to be completed by office
�R }s�:-7� l Map I f Lot / ,/y Unit
Zone O"dayDistrict
Elm S4 Dell CB Dktriet
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name
I � A C-Il 10-, 6 'Floc-CACCe-- e c
/(Pmt) Cureo Maliry_/m3 tzz O ( 6�
Telephone L/ / -
Signature
2.2 Authorized Agent:
Green Collar,LLC 3 Main St.Unit B.South Hadley, MA 01075
Name(Prion Current Mailing Address,
413 532 1517
SignsTelephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building / S"3 q (a)Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee ,./,o
4, Mechanical(HVAC) yyff�'`�
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number o?y
This Section For Official Use Only
Building PertnDaleil Nu r: Issued'
Signa re: L�ea
Builtling SaIV of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thi,column 10 be filled in By
Building Dep.nment
Lot Size
Frontage
Setbacks Front
Side U R:'.. L.: R._..
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Int are.minus bldg&paved _.
arkin
#ofPuking Spaces
Fill _...
valnmc&L atiou
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 DON'T KNOW ODX YES O
IF YES has a permit been or need to be obtained from the Conservation Commission?
Needsto 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 filling)over 1 acre or is it part of a common plan
that will disturb over t 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 applicablel
New House ❑ Addition ❑ Replacement Windows41AMIterations) Q Roofing O
Or Doors ED
Accessory Bldg. ❑p Demolition El New Signs [M] Decks jp /Siding[0] Other[®7X
Brief work: eINgULATIUN%WEATHERIZATION Jd,( 2 �Y ' L/
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
so.N Nov house and or addition to existina..housing. complete the tolkstsinp:
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?
t Method of healing? Fireplaces or Woodsloves Number of each_
g. Energy Conservation Compliance, Masscheck Energy Compliance form attached?
In. Type of construction
1. Is construction within 100 R.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
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 Date
I, ��-li�e�� KCo/'1 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.
l
Print Name
Signal of erlAgent 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
Sig ure Telephone
413 532 1817
i_laanlareeaA Home lmmewmisd Contractor: Not Applicable ❑
Companv Name Registration Number
Green Collar,LLC 181415
Address Expiration Dale
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(8))
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....... DO No...... ❑
11. Home Owner ExeMIDOOD
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such heir eowner to engage an individual for hire who dors not possess a licenu;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 wbn oustr to more than one home in a tw ear 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 Stale 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: 1 BG 6 rA-e17G' 1�92z
The debris will be transported by: ////ff- /IxD 'af'zc,-f
The debris will be received by: IV/14 ,Vd f
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
Permit Authorization
tY1c]SS Sa1/@ Form
Site ID: 3354193 Customer: ALYX AKERS
owner of the.property located at:
(ewneh Nems Pdn,.d)
1006 Florence Rd Northampton, MA 01062
(P,W#nrbreMAddr..) (CRY)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building to perform insulation and/or weatherbation
wrorkon my property.
OW 411110iiii io _
+coa.rs, � ;t.;mx= att aP mG�,,.nn�P n,,y€:ae2mmanowea.Aaarxd+wageawameanmam€nanwaap
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
rorea�ce Us�onN
Rev.102015
The Commonwealth ofMassaehusem
Department of Industrial Accidents
Office of Investigations
9 600 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):
1.® I am a employer with a 4. ❑ I am a general contractor and I 6 E]New construction(full and/or pert-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.insurance.t
required.] 5. ❑ We are a corporation and its ]0.❑ Electrical repairs or additions
3.❑ I 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.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.[TOthednsulation/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 him outside contactors must submit a new affidavit indicating such.
=Contractors that check this box most amalred an additional sheet showing the name of the sub-coutactoa and state whether or not those entities have
employees. If the sub-contactors have employees,they most 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.#: R2WC855214 Expiration Date: 9/23/2018
Job Site Address: 1004, 'Fj�,617[P ,e/ 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 penalties of perjury that the information provided above is true and�correct.
Signature, Date
Phone#: 413 532 1817
Oficial 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 Comigansatlon and Employer's LlabDkv Policy
erkshire Hathaway AMQUARD Insurance Company•A Stock Co.
y Policy Number R2WC855214
Insurance A(IGIUARDCompanies NCRCI No[2187d of 3]
Policy Information Page(AR)
[S]=COLI K and Mailing Address LIC Agency
INSURANCE AGENCY,INC.
3'ltAlfl SMOT UNIT 8 16 NORTH ELM ST
SOUTH HADLEY,KA 01075 Westfield,MA 01085
Agency Code: MATIERI0
Federal Employer's ID 47.1041086 Insured Is Limited Liability Co. (LLC)
[2j Polley Period
From September 23,2017 to September 23, 2018, 1L•01 AM,standard time at the Insured's mailing
address.
[3] Coverage
A. Workers'Compensation Imumr -Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
B. Employers Uabillty Insurance-Part Two of this policy applies to work in each of the states listed
in Rem[3]A. The limits of aur 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 Umited Other States Insurance Endorsement•WC200306B
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of forms
141 Premium
The Premium Basis and, therefore, the protium 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 ; 13,325
Total Surcharges/Assessments f 584.00
Total Estimated Cost 13 909.00
IfirK I USC—ml Page-I - Information Page
MW :R2WC855214 WC 000001A
Deo :1070]/]017
NANOTE
Issuing Office:P.O.Box A-N,16 S.Rlver Street,Wllkes-Bam,PA 18703.0020 a www.guare,corrl
Massachusens Department of Puobc Satet,:;
Board of Building Regulations and Standa
license.CB-10!!77
ROBERT CAL/OW
300 NEWTON ST
SOUTH HADLEY MA 01076
X_ Ezyea. ., .
Commissioner M21MA
C��ie �amo�ta7r-cueccl��i a�C��ccc`ectae�
W Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR U.C. Registration: 191115
a MAN ST.UNIT S. ENliraton: 09/31/2019
SOUTH HADLEY,MA 01075
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