31A-240 (11) BP-2022-0974
55 KENSINGTON AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-240-001 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-2022-0974 PERMISSION'S HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 8321 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2022
Use Group: Owner: TORRES MARIA E
Lot Size (sq.ft.)
Zoning: URB Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON:08/12/2022
TO PERFORM THE FOLLOWING WORK:
INSULATI ON/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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: ( , 1
, I•
I II
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
-v N -o 4,-r
iafFinAvuk flu+u lq' O 406 ,
The Commonwealth of Massachuhettso
W Board of Building Regulations and S1t d > c'Q�� FO
Massachusetts State Building Code,780 �yq r�o��G,^� CI E LITY
Building Permit Application To Construct, Repair, Renovate Or st7. 'evis:' Mar 2011
One-or Two-Family Dwelling so s
This Section For Official Use Only
Building Permit Number: ,01,)-— `Z 7 / Date Applied:
eeti)0(2'55 -- /— 8 17- Z6Z2
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
55 Ke.ns'a Arc
1.1a Is this an accepted-street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: 1
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 0 Private CIZone: _ Outside Flood Zone? Municipal 0 On site disposal system Cl
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Mamma —T'oms Norh `, I.Ao..
Name(Print) City,State,ZIP
66 tensirt ItA Art 943-3581
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 Cil Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
I Naafi t e et ktAAC6e -b WOW S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ g''1 %el ( 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: $
q� Check No.54,g1 7heck Amount: Li' Cash Amount:
6.Total Project Cost: $ U ' 3 a 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 315,000 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)
181415 3/31/2023
Green Collar,LLC HIC Registration Number Expiration Date
HIC Comnanv 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 jto provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes EZI 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:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained' s application is true and 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.gosj/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"
DocuSign Envelope ID:434628D9-F2D5-4307-9D3B-ABD0315735AC
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
Maria Tores
(Owner's Name)
owner of the property located at:
55 Kensington Avenue
(Property Address)
Northampton, MA 01060
(Propert ddress)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a buildin
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.
cDocusigned by:
aY1a I brrt,s
Owngs"S`fdi gtlre
6/18/2022 111:30 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RISEengineering.com
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 (Business/Organization/Individual): Green Collar, LI,C _
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 15 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 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.1X1 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: 55 1(€r\ i/\9j 1b'\ A rC City/State/Zip: kr-arh0, -1-0r .r\l\-0•—•
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.
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#:
�9"� tone- l�
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, M asaphusetts 02118
Home Improvem&Cl ntractor Registration
- ..�,- Type: LLC
3 Registration: 181415
GREEN COLLAR LLC. z,l . . - --= W Expiration: 03/31/2023
- 570 NEWTON ST • k ,y w
SOUTH HADLEY,MA 01075 >. •
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7 q'u`!-r
•
rp a S"."'"*Y
3 Update Address and Return Card.
SCA 1 0 20M-05/17
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
WE,:LLC before the expiration date. If found return to:
ReolstratIcill Expiration Office of Consumer Affairs and Business Regulation
.811 1.. = ="+ 03/31/2023 1000 Washington Street -Suite 710
GREEN COLD , Boston,MA 02118 •
o
A
STEVEN ECKM '
570 NEWTON S .:Ay
T' �4� •
.
SOUTH HADLEY,MA b?6 - Not valid without signature •
• Undersecretary
'T Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Const f 1 ti isor
CS-108817spires 08/23/2022 '
•' .a ROBERT CAiIOU 1 .ill 8 UPPER RIVIJKR R.b I i i Y►1 / fl
SOUTH HADLgY MA 5 i' 5' . ' W`.
r O .
. Commissioner d,0e. K. `YErrulLt&.
d
City of Northampton
Massachusetts *
A
DEPARTMENT OF BUILDING INSPECTIONS470,;
; 212 Main Street • Municipal Building v",4
j: ^r
Northampton, MA 01060 ��7-Pk?
Property Address: rt , €
J
Contractor Green Collar,LLC
Name:
Address: 570 Newton ST
City, State: South Hadley. Ma
413-532-1817
Phone:
Property Owner
Name: t`` 4 T�. ,.
Address: "' x t0 , m►
City. State: t_ d ,
Rob Calhoun (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 %belt Calhoun
Date 8/12/.2
i
Y City of Northampton
'ro �s si
Massachusetts ��s. %._ e
♦ eG
t r m, wt. 3`t
} 4 m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJ� fib'j
Northampton, MA 01060
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 pre-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 beregistered
Type of Work: IYIS. 1 1 cx Est. Cost: O ) ?j2
Address of Work: 5S 1<en Si m.o\-t-a n v-C
Date of Permit Application:
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:
_�"I c^ ►�etrt 00116r Lc-- I I4i
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
�� � ratiY Massachusetts � -
(p� i:`.
N
DEPARTMENT OF BUILDING INSPECTIONS 7 r
212 Main Street •Municipal Building Jti p
Northampton, MA 01060 J'fr g7cs
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:
55 crS) -t-Or. -Vt
(Please print house numbbr and street name)
Is to be disposed of at:
t \' SeN� c_-t 0 --rr ."4—& c;11 , Ck ' C�a
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit 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.