42-136 (2) BP-2023-0067
864 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-136-001 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-2023-0067 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 3853 GREEN COLLAR LLC 108817
Const.Class: Exp.Date: 08/31/2024
Use Group: Owner: SYLVESTER ERIC&ERIKA B ST PETERS
Lot Size (sq.ft.)
Zoning: WSP Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON: 01/19/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ERI ZATI 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:
* flAA. . .
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
1
y/` The Commonwealth of Massachusetts
* ' ^ ` -- Board-of-Building Regulations and Standards MUNICIPALITY
R
✓ //1/ Massachusetts State Building Code,780 CMR USE
r:-,_�,, Buildirmit Application To Construct,Repair,Renovate Or Demolish a Revised M r 2011
af.r,�J One-or Two-Family Dwelling
fn;`;Y ,._ This Section For Official Use Only
0 C
Buildin Permit N;; D 1)2 3-,4(7 Date Applied:
mi..) �Co�S /��� 1-/9-1126z3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 �opet-ly Addre�: 1.2 Ass tsors Map&Parcel Numbers vi
y WCAS MPOP401-) RZd • _ �,
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 1 Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private 0 Municipal 0 On site disposal sys em 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rc or
E.ri ko, Si-.Yea-ers NOr-4-hampkon . Mo. .
Name(Print) City,State,ZIP
B(oy Wes-Ehc k- Ra . yt3-335-AacQ ehS boo@ ant . c t,1y\
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other W Specify:Insulation/Weatl)erization
Brief Description of P o osed Work2: Insulation/Weatherization
- cc. oor - \5" _opfin b\ov.) ce.l,\ u,\05c - L l oois)
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) _
1.Building - $ Si$5 3. ee I. Building Permit Fee:$ Indicate how fee is dtermined:
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 F
6.Total Project Cost: $ 3,�53 •ao
Check No. Check Amount: �J� Cash Amount:
❑Paid in Full 0 Outstanding Balance Due:_
a
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 8/23/2024
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 35,00) 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)
Green Collar,LLC 181415 3/31/2023
HIC Registration Number Expiration Date
HIC Cot/many Name or HIC Registrant Name
570 Newton St Support@greencollarma.com
No.and Street
South Hadley,MA 01075 413 532 1817 Email address
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: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 in this al)! ' atio is true and accurate to the best of my knowledge and understanding.
- a3
Prin_Owner's or Ai orized 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 t.m 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
07.
Office of Investigations
600 Washington Street
T>. 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 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 11.0 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.® Othetinsulation/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.#: R2WC182010 Expiration Date: 9/23/2023
Job Site Address:c8,(o'4 W e M-k4'M p r' Qd . City/State/Zip:MD(' -h Ono • 1�'1 o .
Attach a copy of the workers' compensation policy declaration page(showi nd a iration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimin 1 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 RDER 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 ffice 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 #:
V.
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Reg I rations and Standards
Const, ion S rv►sor
1~ y
CS-108817 u E%pires:08/23/2024
ROBERTCR
8 UPPER R RD
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SOUTH HADL Y MA %
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ComrnissiIIncr
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•///�� '/ir//////i��///'%/1//� ��.. /(i/.///77 /1/N14
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: 03/31/2023
570 NEWTON ST
SOUTH HADLEY,MA 01075
Update Address and Return Card.
SCA I 0 20n1-O51-
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
181415 03/31/2023 1000 Washington Street -Suite 710
GREEN COLLAR LLC. Boston,MA 02118
STE\,EN ECKMAN
570 NEWTON ST y�.x s .;
SOUTH HADLEY,MA 01075 Not valid without signature
Undersecretary
4
Permit Authorization
mass save Form
Site ID: 4705305 Customer: ERIKA ST PETERS
I, Erika St. Peters , owner of the property located at:
(owner's Name,printed)
864 Westhampton Rd Northampton, MA 01062
(Property Street Address) (City)
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.
ERJK4 drPEi7RS
Owner's Signature:
Date: 01 / 09 / ...
eloo tiosoamr milmo *****0.* 4000r40......400,. 41...40*. ►...0,0040 411
00000
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:
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