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32A-067 (3)
BP-2022-0334 53 UNION ST COMMONWEALTH OF MASSA HUSETTS Map:Block:Lot: 32A-067-001 CITY OF NORTHAMPT I N Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FU D (MGL c.142A) BUILDING PE ' I IT Permit# BP-2022-0334 PERMISSIONIS H;REBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 1344 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: MERTEN NER ,JENNIFER M &RYAN L Lot Size (sq.ft.) Zoning: URC Applicant: GREEN COLL•R LLC Applicant Address Phone: Insurance: 570 NEWTON ST (413)532-1817 R2WC1182010 SOUTH HADLEY, MA 01075 ISSUED ON:05/13/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHA PTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1 ► A. Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 5-I4d--iciEe-r,--kt-xr--#-ErrriPft 1 The Commonwealth of Massachusetts lfi. APR - 4 2Q22 Boardof BuildingRelations and Standards FOR C Massachusetts State Building Code,780 CMR MUNICIPALITY USE ----nc ikiinee it tripl ication To Construct,Repair, Renovate O Demolish a Revised Mar 2011 r.:'t!1,, � tni,-,r:=CTIC a One-or Two-Family Dwelling This Section For Official Use Only i Building Permit Number: A P.).ti 33'/ Date Applied: KnEv,� ' 70s5 // 5- 13-2ozz Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map&Parcel N ers 1.1 IsthisanMap Number Parc�r a accepted street?yes no 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.a Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? M icipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP 2.1 nert of Record: Senn,�e r N en) NOrOampttr . Name(Print) City,State,ZIP 53 iW1\ S# q13- -gal(o No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(cteck all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) I❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ei Specify:Insulation/Weatherization Brief Description of Proposed Work2: Insulation/Weatherization Ir\s4axt RA CiOrrojk.oSS -to aat S 4 era.( S(TLkc e \nSA tr.tk (O Cc,lk '(bLj to 3Sa sewe-4- SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ ) , 3(4 3 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No.666 Check Arnow-165. Cash Amount: 6.Total Project Cost: $ I -y 2 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 South Hadley,MA 01075 U Unrestricted(Buildings up to 35,000 cu.ft.) South City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413 532 1817 Support@greencollarma.com I Insilation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 181415 3/31/2023 Green Collar,LLC _ 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 BL'ILDING 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:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I h- - .ttest under the pains and penalties of perjury that all of the information conta''r"i ,se- •plica ' - and accurate to the best of my knowledge and understanding. Print 0 er's • thorized 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 roo+n 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" City of Northampton // ~ Massachusetts l � DEPARTMENT OF BUILDING INSPECTIONS % 212 Main Street • Municipal Building yJ�. CDC ` Northampton, MA 01060 r d11 ,1� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: ( Se�v\cg-5 - t,\,, , erj. Ckty- r The debris will be transported by: Name of Hauler: (�� ( ritC (' Signature of Applica i Lam, l" Date: The Commonwealth of Massachusett Department of Industrial Accidents ci. _xf Office of Investigations 4.4--ta L ' = ; 600 Washington Street Boston,MA 02111 .r„ 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 /5 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.t required.] 5. ❑ We are a corporation and its 10.1=1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.M 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. tContractors 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.#: R2 W C 182010 Expiration Date: 9/23/2022 Job Site Address: 53 Ui i'Ors Si-. City/State/Zip: /jOfr fUn' Ai-A' Attacha 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 nay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. 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#: i ACo® CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) 1 a27/2027/zoz 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Denise Sawicki NAME: Amherst Insurance Agency Inc (INC IQ E ): (413)253-5555 No): (413)256-8354 20 Gatehouse Rd. EMAIL dsawicki©nathanagencies.com ADDRESS: P.O.Box 48 INSURERIS)AFFORDING COVERAGE NAIC B Amherst MA 01002 INSURERA: CRC Group INSURED INSURER B: Preferred Mutual 15024 Green Collar LLC INSURER C: Scottsdale Insurance Company 570 Newton Street INSURER D: INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21102703683 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUUR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD, POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 NIED CLAIMS-MADE t OCCUR PREMISES(DAMAGE I Ea occurrence) $ 100,000 "r MED EXP(Any one person) S excluded A 771BG0552101 10/25/2021 10/25/2022 PERSONAL 8 ADv INJURY f 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY Ti ECa'T El LOC PRODUCTS-COMPIOP AGO S 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED PCA0100300842 08/27/2021 08/27/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Peracadont) X UMBRELLA UAB OCCUR EACH OCCURRENCE S 2,000,000 C EXCESS LIAB CLAIMS MADE XBS014069 10/25/2021 10/25/2022 AGGREGATE S 2,000,000 DED RETENTION S S WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A E.L.EACH ACCIDENT S (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S $1,000,000 Pollution Coverage A G28375748001 01/20/2022 10/25/2022 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORO 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD oocuSign'Envelope ID:D3595286-12B4-498D-A697-EDBCD7163C59 RISE ENGINEERING" OWNER AUTHORIZATION FORM Jennifer Nery (Owner's Name) owner of the property located at: 53 Union Street (Property Address) Northampton, MA 01060 (Property Address) hereby authorize �l .Tl (.5( 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. —D'u^^cuASi'gncd by. �� MAI Ow'r esy 'P rigt e 1/16/2022 I 10:03 PM EST 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 vr Massachusetts *" -� es; DEPARTMENT OF BUILDING INSPECTIONS E# 212 Main Street • Municipal Building Jars, ,z Northampton, MA 01060 fh 4'? MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 53 Union ST Contractor Green Collar,LLC Name: Address: 570 Newton St City, State: South Hadley Phone: 413-532-1817 Property Owner Jennifer Nery Name: Address: 53 Union ST City, State: Northampton,Ma I, Green Coilar,LLC (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 Robert Calhoun Date 5/13/22