36-051 (4) 12 WHITE PINE DR BP-2019-0467
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-051 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinn DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0467
Project# JS-2019-000750
Est.Cost: $2000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq. ft.): 13024.44 Owner: NEAL DAVID B&JOANNE
Zoning: A_pulicant: GREEN COLLAR LLC
AT: 12 WHITE PINE DR
Applicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:10/18/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD CELLULOSE TO ATTIC FLAT
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 DeuartMent 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 10/18/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
ZAIS UG 7 CltV
EC City of Northampton
E v Building Department
r �
212 Main Street
JOCA
15 2018 Room 100 �
Northampton, MA 01060
One13-587-1240 Fax 413-587-1272EPT OF pUILING{NSPECORTHAMPTONMA 01060APPLICATION STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR IW�O FAMILYDWELLING
SECTION 1 -SITE INFORMATION
This section to be comphOd by Wdi
1.1 ProDert/Address:
t Map Lot' /,�� Un
zone OVWWDWO
tam at.Dftb t CS 0111116W_
t
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
(11A.,
Name(Print) Current Mailing -
Address
3- Svc/,- y-7ao
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Anent:
Green Collar,LLC 351 Newton St. Unit B.South Hadley, MA 01075
Name(Print) Current Mailing Address:
413 532 1817
Signata re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing e. - Building Permit Fee
4. Mechanical(WAC) C
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This SeWon For Official Use Only
Building Permit Number. Date
Issued:
Signature: 101466
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 fitted 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 i
#of Parking Spaces
__ ... _.... _
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW QX YES Q
IF YES, date issued&
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES
IF YES: enter y"Book Page and/or Document At
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW OX YES 0
IF YEA has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained
Q Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any propo changes to or additions of signs intended for the property? YES ® NO Q
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 Q NO OX
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SMC71ON S-DESCRIPTION OF PROPOND WORK(check all [p, kable)
New House [] Addition ❑ Replacement Windows Alteratlon(s) ❑ Roofing ❑
or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [p Siding(o) Other[m)X
Brief DoWork:-1R ti n of Pr �dd 44 "" e �� J ® � A�:
IN�uLATIC�3/WEATHERIZATION t'1'C� C z! y�
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
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.
1. 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
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.
Print Name
S of ownerlAgent Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O
Nwne or license Holder: CS-108817
Robert Calhoun License Number
8/2312020
Address Expiration Date
390 Newton St.South Hadley,MA 01075
Signature Telephone
le /7 413 532 1817
Com'- Not Applicable 13
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
351 Newton 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....... M No...... 1
M�4Hk*'O*rbii 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 fano
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 nertb imied 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 injtries not resulting in Dearth)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this penmit.
The undersigned"homeowner"certifies and assunnes 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
.11
Columbia Gas.
of lVlass�WeM 60 Shawmut Road,Unit 2 Canton,MA 02021
A NWOUrW CWHP&W
OWNER AUTHORIZATION FORM
1, David Neal
(owners Name)
owner of the property located at:
12 White Pine Drive
(street)
Florence, MA 01062
(Town,State,Zip)
hereby authorize
(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 dose out this permit by contacting their municipality at the completion of this work.
-Customer Signature
-Sign Date
5/7/2018
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: t 2 "Ak Ve-.
The debris will be transported by: /:'/� / 7
The debris will be received by: � An
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
IF 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: 351 Newton 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_ 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
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 me in an capacity. employees and have workers'
Y p tY• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 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 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.
lContractors 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.#: R2WC855214 Expiration Date: 9/23/2019
Job Site Address: /Z lA:k— Azu a, 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
.es
Sijznature ~� Date: CC��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#:
A _ ' Worker's Comi2ensation and Employer's Liability Policy
Berkshire Hathawa AmGUARD Insurance Company - A Stock Co.
� Y Policy Number R2WC988571
Insurance Renewal of R2WC855214
RAP& G U A R D Companies NCCI No. [21873]
r
Policy Information Page (AR) is omit .4
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit B 16 NORTH ELM ST
South Hadley, MA 01075-2351 Westfield, MA 01085
Agency Code: MATIER10
Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC)
[2] Policy Period
From September 23, 2018 to September 23, 2019, 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-WC200306B
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 $ 10,852
Total Surcharges/Assessments $ 389.00
Total Estimated Cost 11 241.00
INTERNAL U5E XX Page - i - Information Page
MGA : R2WC988571 WC 000001A
Date : 09/04/2018
MANOTE
Issuing Office: P.O.Box A-H, 16 S.River Street,Wilkes-Barre,PA 18703-0020 • www.guard.com
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
con stnwfiri tt*,prvisor
Cs-108817 Ispires:08/23/2020
1111041m C
3"NEWTON
SOUTH HADL
Commissioner
Office of Consumer Affairs and Business RegUla�tion
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Horne Improvement Contractor Registration
Typex LLC
GREEN COLLAR LLC. Retgis mMon: 0 03/313
3 MAW ST.UNIT S.
3J31/201f�
SOUTH HADLEY,MA 01073
Update Address and return card. Mark rwaon for otrenge.
SCA I 0 20M-061i y [ ) /j / 0 Aeidms 0 Renmrd 0 Em0oyms A 0 Lost Card
lt
0 ill OW
t"o
nil, ofCoraunterAffoolkauskamensouloon
HOME IMPROVEMENT CONTRACTOR Registration valid for kxNvWW use only
aTYPE:LLC beWra the exon elate. N found return tax
bakift office e#Consumer Affa m and Business RepWadon
181415 ata 03f3112019 10 Park Plata-ate 5170
GREEN COLLAR LLC. Boeton,MA 02118
STEVEN ECKMAN
3 MAIN ST.UNIT S. • �c
SOUTH HADLEY.MA 01078 Underasc"—I Not valid Without signBtum