29-262 (7) 92 LONGVIEW DR BP-2019-1085
GIS 4, COMMONWEALTH OF MASSACHUSETTS
Map,Btock:29-262 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-2019-1065
Proiect 4 JS-2019-001768
Est Cosi$2569.0
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group GREEN COLLAR LLC 108B17
Lot Size(sg ft.} 16335.00 Owner: HICKS ALAN G
Zori= Applicant: GREEN COLLAR LLC
AT: 92 LONGVIEW DR
AApplicant Address: Phone: Insurance:
3 MAIN ST UNIT B (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:4/212019 0:00:00
TO PERFORM THE FOLLOWING WORX.•INSULATION
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: 2i 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 4/2/2019 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 Northampton Status.of Perms
Building Department Curb CurNriveway Permit
212 Main Street Sewer/Septic Avallabdity
Room 100 WatedWell Ave4abft
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 ploVSite
olhe 5
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH ONE OR TWO FAMILY EL ING
SECTION t -SITE INFORMATION APR 1 2019
1.1 Property Address: T iax o ce
DEPT OF BUILDING 1NSPEcn0Na
Map M HAMPTON,MA01060
Z l.oYi�V i &w fit.
1 Zone Overlay District
4�(D'Z Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-�I axe H �C KJs
Name(Print) Current Wild,Address:
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Apert:
Green Collar, LLC 351 Newlon Sl. Unit B.South Hadley,MA 01075
Name(Pnni) Current Mailing Address:
413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building 31, 5 W q (a)Building Permit Fee
2. Electrical V/ (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVACLQ
)
5. Fire Protection
6. Total=(1 +2+3+4+5) 5 t Check Number
This Seaton For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspedw of BuBdifte Date
Section 4. ZONING Ad Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
'lois column to be filled in by
Building reenactment
Lot Size
Frontage
Setbacks Front
Side L: R: U R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
(Loi area minus bldg&paved
Docking)
#of Parking Spaces
Fill:
vlbcme
&Location
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 YM enter BookPage and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW g5X YES O
IF YF$, 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 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 1 acre? YES O NO (K 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 Alterations) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ Naw Signs [O] Decks ID Siding[0] Other[MX
Bdef Descri tion of Pro psetl
Work: IK9ULATI6og/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
Be.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?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of healing? Fireplaces or Woodsloves 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 ra-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, C7 rP.Q fA (1 �� A 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.
Prim Name
I�
Sin of Owner/Agent Data
SECTION e-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun 8/23/2020
Address Expiration Date
390 Newton St. South Hadley,MA 01075
Signature Telephone
413 532 1817
S.Realstared Home IMM—mant Contractor: Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Dale
351 Newton Sl. 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(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 structmcs accessory to such use and/or farm
structures.A Person h constructs more than home in a two-year Period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a forth 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 offer work for which this permit is issued.
Also be advised that with reference to Chapter 152(W rri 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 mf 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: q2 A\i i.Q W 7f t R o r-enC-e.
The debris will be trLnsported by:
The debris will be received by: Z �a�1,01 c SQ, ), (,P,B
Building permit number:
Name of Permit Applicant Zclb C. obboon
Date Signature of Permit Applicant
DocuSlgn Envelope ID:93E92A68-8410AE90-A1EA-D16B2B31223F
Aft Permit Authorization
mass Save Form
Site ID: 3683153 Customer: ALAN HICKS
Alan Hicks
I, ,owner of the property located at:
(Owner's Name,prlmeEl
92 LONGVIEW DR FLORENCE, MA 01062
Qrgperty Street Atltlress) (aryl
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 on my property.
C
ooeusgnea er
Owner's Signature: N CSS
Date: 2/13/2019 15:08 PM EST
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
C`1«2Y� ��\r,Lr 3/1q/lq
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page, 1 of 1 Por Mo.U.Only
Rev.102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Basincss/Organization/individuap: 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.® 1 am a employer with_ i 2 4. ❑ I am a general contractor and 1 6 ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P Y 9. ❑ Building addition
rworkers' comp. insurance camp. insurance./
required.] 5. ❑ We are a corporation and its 10.❑ 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.® Othednsulation/Weatherization
comp. insurance required.]
*Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit mdica5ng such.
tContractors that check this box most attached an additional,beet 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 k 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: 12.- LnnAIM) Dr City/State/Zip: Fio(',eq et, AA GIOU
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 nue and correct.
Si tatr•� \n �� Dut• / 2q /I�
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#:
Worker's Compensation And Emolovees LIeb1Ii[v PoIIN
Berkshire Hathawa AmOUARD Insurance Company-Ast- CO.
y Policy Number R2WC988571
55214
GUARD Companles RenewalNCCI No.[21873]
Policy Information Page(AR)
[37111amed Insured and Nailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit B 16 NORTH ELM ST
South Hedley,NA 01675.2351 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.
[31 Coverage
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation
Law of the fallowing states: Massachusetts
B. Employers 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 acddent $500,000
Bodily Injury by Disease-each employee 1500,000
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 In burnation Page-Schedule of Forms
(4] Premium
The Prmdum Basis and,therefore,the premium will be determined by our Manual of Rule,
Classifications, Rates,and Rating Plans. NI required Information Is subject to verification and change by
audit. (Continued on another page)
Teal End naNd Policy Premium $ 10,852
Total Surchargas/Asswments $ 389.00
TOM 40msta0 Cost 11 1L241.00
mneeuu use xx Page-1- Information Page
peM :R3wc pl WC 000601A
eases
Issulaill Oman P.O.in A-H,16 s.aye Street,wiliw•Bars,PA 18703.0010 9 www.guard.Cer[r
.Te ��zr�zrmutea��c����s-su���ells
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Regxpiraion: 181415
351 NEWTON ST UNITE Expiration: 03/31/2021
SOUTH HADLEY,MA 01075
Update Address and Return Card.
SCA I O 2)M1 17
OMca of C....Malre 6 alulnaas Rasuktlon
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC before ilia expiration data I/found return to:
Rida fdgiration Off.of Consumer Affairs..it Business Regulation
181415 ON3112021 1000 Washington Street-Suite 710
GREEN COLLAR U.C. Boston,MA 02118
STEVEN ECKMAN 1
351 NEWTON ST UNIT 8
SOUTH HADLEY.MA 01075 Undersecretary Not valid without signature
Commainwealth of Massachusetts
Division of Professional Lkensure
Board of Building Regulations and Standards
Construction Supervisor
CS-108817 EApires: D8/23/2020
ROBERT CALHOUN
830 NEWTON STREET
SOUTH HADLETINIA gdgle
Commissioner