24D-251 (2) 94 CRESCENT ST BP-2020-0910
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-251 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 P E RM I T
Permit# BP-2020-0910
Proiect# JS-2020-001548
Est.Cost: $7305.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: - GREEN COLLAR LLC 108817
Lot Size(sq.ft.): 21213.72 Owner: PARADISE THEODORE
Zoning: URC(100)/ Applicant. GREEN COLLAR LLC
AT. 94 CRESCENT ST
Applicant Address: Phone: Insurance:
390 NEWTON ST (413)532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.211012020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC 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: 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 2/10/2020 0:00:00 $65.00
212 Main Street, Phone(413).587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
v -• 1 Dep
OR
City of Northa ton / ,"-
.�► Building Depar-tmen FES
212 Main Street SULATION
Room 1'00 1"r 7' � � �0
Northampton, MA 01 ONK9
phone 413-587-1240 Fax 413- I'f27r'�s�Fc ONL
lq 07p� SNS
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELL I ONLY
SECTION 1 -SITE INFORMATION _ INSULATION PERMIT
1.1 Property Address: This section to be completed by office
Map al Lot -;LS Unit
0`Ob b Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
—V,to&jr e, Pur et OLL -(.) QU Or e scont 1 -wt t rt N aro, cA"AtV1
Name(Print) Current Mailing Address:
Nil a;tk-0.ch-eon Telephone J,�3-
Signature
2.2 Authorized Aaent:
6 on 06b-, LLC, a tiP &G6"A �40-
Name( nt) Current Mailing Address: (�
U'� A13- S32 rl
SignalLfe Telephone
SEC ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant_
1. Building Vrj (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= 0 +2+3+4+5) Check Number
This Section For Official Use Only
p� --
Building Permit Number: Date
Signature: 61&m2
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor:
` 11 � Not
Applicable C❑l n
Name of License Holder: {.!1►�C/l�� lella.11,A `� 1 O� "1 - `
License Number
c3go U w�A &ireu �s cam, �A ad l,2 Irl 0(0 7- 2 a 2
Addre Expiration Date
I
Sign re Telephone
9 Reclstered Home Improvement Contractor: Not Applicable ❑
(CJS v , c� I 1 L4
Company N�e� \lam �� Registration Number
LIS I b) tunP 0-f a� 3 � - 2 l
Address Expiration Date
Telephone
SECTION 5-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....... No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
i - I
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.
LO��t C0A. 1 v u rL
Print NAMe
Sign f Own r/Agent Date
��11..
�( r as Owner of the subject
property
CIX
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
_ City of Northampton
Massachusetts
f
{, DEPARTMENT OF BUILDING INSPECTIONS
212 Main street •Municipal Building
Northampton, MA 01060
Debris 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.
The debris from construction work being performed at:
qq Ck t, C�Uj ire Q,4,—
(Please print house number and street name)
Is to be disposed of at:
P,9.Q Abu c, c�-r v Ce�2s $q5 goof" o coca + 2+-
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signatur ermit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
-- City of Northampton
' xr 255 � S�ci
Massachusetts
f.'
DEPARTMENT OF BUILDING INSPECTIONS S
212 Main Street • Municipal Building
Northampton, MA 01060 �SNh `�O
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: Gu �d e.SU4t--e &ru-k V�oAoon�n— NKA A 0 �D
Contractor
Name: C 252.(L (�O��G� L C.
Address: N w't�
City, State: CL Q 0 10 (1 S
Phone: 4A& S a- I � l r7
Property Owner
Name: �,OC�C� �CI�Y CIC
Address: C[�r- _��
City, State:
(contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
DocuSign Envelope ID:ElEA5163-9159-48BE-9D5A-C3136B31D602
Permit Authorization
mass save Form
Site ID: 3950416 Customer: Theodore Paradise
l� Theodore Paradise , owner of the property located at:
(Owner's Name,printed)
94 Crescent St Northampton, MA 01060
(Property Street Address) (cam)
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.
DocuSigned by:
Owner's Signature: tL,bhV' �aYa�iSt
".,.,.......
Date: 1/31/2020112:59 PM EST
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:
Page 1 of 1 For office Use Only
RPV. in2015
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/El pl ase Print m ibly
er
Applicant Information
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):
4. EJ I am a general contractor and I 6 E] New construction
1.® I am a employer with =� have hired the sub-contractors
employees(full and/or part-time).* 7. Remodeling
listed on the attached sheet.
2.❑ I am a sole proprietor or partner- These sub-contractors have g. F] Demolition
ship and have no employees
working Ibr me in any capacity. employees and have workers' 9 E] Building addition
� comp. insurance.
insurance i10.❑ Electrical repairs or additions
[No workers' comp.
5. We are a corporation and its
required.] officers have exercised their 11.E] Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of per on exem tiMGL 12.❑ Roof repairs
myself. [No workers' comp. p p
c. 152, §1(4),and we have no
insurance required.] t employees. [No workers' 13.[9 OtherInsulation/Weatherization
comp. insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
then hire outside contractors must submit a e
t Homeowners who submit this affidavit i hid to additional ing they aredoing showing the namc of the suboinall work an -contractors and state whether or not hose entities have such.
lContractors that check this box must t
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. AmGUARD Insurance Company - A Stock Co.
Insurance Company Name:_
Expiration Date: 9/23/2020
Policy#or Self-ins. Lic.#: R2WC053509 p
Job Site Address:
"1 '"l l X -?-S 0 01l 7L
Attach a copy of the workers' compensation policy declaration page c. (showing can lead the policy number
er and expiration
crimia penalties nate a
Failure to secure coverage as required under Section 25A ofRK
fine up to $1,500.00 and/or one-year imprisonment,as well as civilpenalties
n isies in the
m f forwarSTOP edOto h Office ofd a fine
of up to$250.00 a day against the violator. Be advised that a copy of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thf pains and penalties of perjury that the information provided above is true and correct
Signature:
Date:
—
—
Phone#: 413 532 1817
FOfficial only. Do not write in this area,to be completed by city or town ofjiciaLwn•
Permit/License#
Issuing Authority(circle one):
own Clerk 4.Electrical Inspector 5.Plumbing Inspector
1.Board of Health 2.Building Department 3.City/T
6.Other
Phone#:
Contact Person:
Worker's--Compensation and Em 31over's Liability Policy
AmGUARD Insurance Company- A Stock Co.
..v�Berkshire Hathaway Policy Number R2WC053S09
Insurance Renewal of R2WC988571
@
GUARDCompanies NCCI No. [21873]
Policy information Page (AR)
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC TIERNEY INSURANCE AGENCY, INC.
351 Newton St Unit B PO Box 750
South Hadley, MA 01075-2351 Westfield, MA 01085
Agency Code: MATIER10
Federal Employer's ID 47-1041086 Insured is Limited Liability Co. (LLC)
Risk ID Number 1038965
[2] Policy Period
From September 23, 2019 to September 23, 2020, 12:01 AM, standard time at the insureds mailing
address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
of this policy applies to work in each of the states listed
B. E<mployer_s Liability Insurance - Part Two
In item [3]A. The limits of our liability under Part Two are: 500,000
Bodily Injury by Accident - each accident 500,000
Bodily Injury by Disease - each employee 500,000
Bodily Injury by Disease- policy limit
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 $ 16,348
Total Surcharges/Assessments $ $S53.00
Total Estimated Cost $16,901.00
INTERNAL u5E 81 Page- 1 - information
000001A
MGA :R2WC053509
Date :09/13/2019
MANOTE
Issuing Office: P.O. Box A-H,39 Public Square,Wilkes-Barre, PA 18703-0020 9 wvwv.guard.com
7 -t
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
Registration: 181415
GREEN COLLAR LLC. Expiration: 03/31/2021
35'f NEWTON ST UNIT B
SOUTH HADLEY,BAA 01075
Update Address and Return Card.
SCA 1 O 20M4W17
Office of Consume'Affair&Business Regulation Registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
TYPE:LLC Office of Consumer Affairs and Business Regulation
112 Fxni nII 1000 Washington Street-Suits 710
181
Boston,MA 02118
GREEN COLLAR LLC.
STEVEN ECKMAN
351 NEWTON ST UNIT B Not valid without signature
SOUTH HADLEY,MA 01075 Undersecretary
Commonwealth of Massachusetts
®' Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-108817 E4pires: 08/2312020
4 �
ROBERT CALHOUN ,
390 NEWTON STREET
SOUTH HADLEY'MA 0197$
s.
Commissioner