38B-082 (3) BP-2022-001 1
165 SOUTH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-082-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0011 PERMISSIONISHEREBYGRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 1705 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2022
Use Group: Owner: UG SOUTH, LLC
Lot Size (sq.ft.)
Zoning: URB Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI 182010
SOUTH HADLEY, MA,01075
ISSUED ON:01/04/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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.
Signature:
,2
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
1
t
The Commonwealth of Massachusetts '`-� f I
Board of Building Regulations and Standards miThaFOR
Massachusetts State Building Code.(1): , 780 CIPALITY
2QZZ USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling _ I
This Section For Official Use Only .,
Building ermit Number: !7/'n
' 2 /i Dale Applied:
6.010 a /7 --2 I. 3-115Zz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
110 6 €auN'I S+.
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: Outside Flood Zone?
_ Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
I50C ha/We ran , Ma. o woo
Name(Print) City,State,ZIP
I65 QUAtt St a03- e1r-(0831
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other lCa Specify:Insulation/Weatherization
Brief De cri tion of Pro osed Work2: Insulation/Weatherization
kp rct TO aKO ,Tgtft CrywAStCQ
V -S4-0wl ellty& ID010-r-ak. 1-0 iti S S tr-+ ing.f-mot--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ I r105- 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Feed
Check No.'U1f heck Amount: Cash Amount:_
6.Total Project Cost: $ 1 1 OS-- 0 Paid in Full 0 Outstanding Balance Due:
/ SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 8/23/2022
CS-108817
Robert Calhoun License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
390 Newton St.
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
South Hadley,MA 01075 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413 532 1817 Support@greencollarma.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 3/31/2023
Green Collar,LLC 181415
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
570 Newton St Support@greencollarma.com
No.and Street Email address
South Hadley,MA 01075 413 532 1817
City/Town,State,ZIP Telephone
SECTION 6: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 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below, e attest under the pains and penalties of perjury that all of the information
contain this applica' is true d accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
DocuBign Envelope ID:329826CD-9451-4E2F-A02F-03CE6596EBDE
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
Ali Urbano
(Owner's Name)
owner of the property located at:
165 South Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize ( ,_tQri l(ar i GLC-
Subcontractor to be filled in by office)
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 subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
,-DocuSigncd by.
IILi Uvtsaate
Owr3vs"gil ffgMYre
10/22/2021 11:45 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
City of Northampton
QYH3M f
SAC
Massachusetts ��� �-• '<11
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DEPARTMENT OF BUILDING INSPECTIONS ?s: ti M
212 Main Street • Municipal Building Jp �L
. y..w' Northampton, MA 01060 N %��''
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pm-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: l r1,SIII bah p l\ Est.Cost: 1170 c
Address of Work: S gGu 'h S}'.
Date of Permit Application: 1247//4.Z..
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
fad /r C G1Icv, u. c I[(1LI 1 5-
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
- : Sys S,c
•� & Massachusetts
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� DEPARTMENT OF BUILDING INSPECTIONS S :;
212 Main Street • Municipal Building
Northampton, MA 01060 ss1.w
Massachusetts Residential Building Code
Section 110.R5.1.2
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.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
• City of Northampton
0. H M ros As 'S/C
i'''# ti, Massachusetts ��+ �-- '�t
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DEPARTMENT OF BUILDING INSPECTIONS
s ..
212 Main Street •Municipal Building Jtif ���
y, 1. Northampton, MA 01060 TbjY 7\1
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:
I (i) 5 S6 S4-
(Please print house number and street name)
Is to be disposed of at:
g-j2)
)ItibLI,C .Q,(V is Ce3
( lease print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
611/(\. ( I ct,17
(Company Name arnd Address)
Signs ure o p scant 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.
' z Worker's Compensation and Employer's Liability Policy
c!Berkshire Hathaway AmGUARD Insurance Company - A Stock Co.
j y Policy Number R2WC248393
'A NCCI No.
GUARD Companies RenewalInsurance C182010
[21873]
Policy Information Page (AR)
I[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC AMHERST INSURANCE AGENCY INC
570 Newton St PO Box 48
South Hadley, MA 01075 Amherst, MA 01004
Agency Code: MAAHER10
Federal Employer's ID XX-XXX1086 Insured is Limited Liability Co. (LLC)
Risk ID Number 1038965
[2] Policy Period
From September 23, 2021 to September 23, 2022, 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)
0
O
U
Total Estimated Policy Premium $ 21,269
Total Surcharges/Assessments $ $858.00
Total Estimated Cost $22 127 00 ,.,.
INTERNAL USE xx Page - 1 - Information Page
MGA : R2WC248393 WC 000001A
Date : 09/07/2021
MANOTE
Issuing Office: P.O. Box AH, 39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
r4
, Office of Investigations
600 Washington Street
Boston,MA 02111
• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Green Collar,LLC
Address: 570 Newton St
City/State/Zip: South Hadley, MA 01075 Phone#: 413 532 1817
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with /3� 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I 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.
*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
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.#: R2WC 182010 Expiration Date: 9/23/2022
�'
Job Site Address: �(��c��+O� (SA City/State/Zip: "
Attach a copy of the workers'compensation policy declaration page(showi nd 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 pedury that the information provided above is true and correct.
Sras`a5tc..
Signature: Date:
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#: