25C-155 (4) 5 ORCHARD ST BP-2021-1388
• GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 155 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 PERMIT
Permit# BP-2021-1388
Project# JS-2021-002312
Est.Cost:$4178.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(su. ft.): 6882.48 Owner: MACDONALD MICHAEL A
Zoning: URB(100)/ Applicant: GREEN COLLAR LLC
AT: 5 ORCHARD ST
Applicant Address: Phone: Insurance:
351 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:5/25/20210:00:00
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. T11
•, ; . -
Certificate of Occupancy signatur`:
FeeType: Date Paid: Amount:
Building 5/25/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
to., City of Northampton Status of Permit:
:uilding Department Curb Cut/Driveway Permit
SAY 2 4 212 Main Street Sewer/Septic Availability
�02� Room 100 Water/Well Availability
r r orthampton, MA 01060 Two Sets of Structural Plans
p' - ' 3-587-1240 Fax 413-587-1272 Plot/Site Plans
nTON "{n,n`!O'�s Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map 421 Lot / 66 Unit
S-/r
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
M,,h.a M4cdove:,.\ S ,Urlfy►•r„n.(\oi•. Nit OIUlaD
Name(Print) Current Mailing Address:
cf , - SN--z1 t A
SEE ATTACHED DOCUMENT Telephone
Signature
2.2 Authorized Agent:
Green Collar,LLC 570 Newton St South Hadley, MA 01075
Name(Print) Current Mailing Address:
413 532 1817
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
14 11 0
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee i)(06
4. Mechanical (HVAC)
5. Fire Protection ,may/�
6. Total = (1 + 2 +3 +4 + 5) ! �7 k. S C Check Number
_ I This Section For Official Use Only
Q--°/ / Q Date
Building Permit Number: 3 � Issued:
Signature: //(' 5-Z5-7-0Z1
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW ®X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ,:4 X YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 14 X
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [p Siding[ID] Other RZ1IX
Brief Description of Proposed
Work: INSULATION/WEATHERIZATION
Alteration of existing bedroom _ Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, SEE ATTACHED DOCUMENT ,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
Signature of Owner Date
I, 006 £GA!Iwv h ,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.
ac,lj COI lil,-l/l
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS-108817
License Number
Robert Calhoun
08/23/2022
Address Expiration Date
8 Upper River Rd, South Hadley MA,01075
Signat� Telephone 413 532 1817
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Green Collar,LLC 181415
Address Expiration Date
570 Newton St, South Hadley, MA 01075 Telephone 413 532 1817 03/31/2023
SECTION 10-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 W No 0
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of 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.
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.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: S otchc.t The debris will be transported by: Gr 04K C o o r
The debris will be received by: P.74‘ 00 Ott r, <<t brow S+ Sx4i%Ha i4114 04°-is--
Building permit number:
Name of Permit Applicant ah Ca Ihoc-h
Date Signature of Permit Applicant
°, - City of
Massachusetts
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GGREEN
COLLAR
Permit Authorization Form
Michael MacDonald
(Owner's Name)
Owner of the property located at:
5 Orchard Street Northampton, MA
(Property Address)
(Property Address)
Here by authorize Green Collar, a certified Mass Save Independent Insulation
Contractor, to act on my behalf to obtain a building permit and to perform work on
my property.
CO-7G E,Unc74 17c4 Z)
(Owner's Signature)
5/14/2021
(Date)
351 Newton St. Unit B South Hadley,MA 01075 Phone:413.532. 1817 Email: support@greencollarma.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, 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 IS 4. ❑ I am a general contractor and I6. [' 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 I 0.0 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' 13.1M 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: 9/23/2021
Job Site Address: S a rat." City/State/Zip:,u00,,,,.(ahh, ,%%4 nloisti'
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 certif under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 5Ir7/a
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#:
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.
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
STEVEN ECKMAN
570 NEWTON ST G �i dGfosdtc"
SOUTH HADLEY, MA 01075 Not valid without signature
Undersecretary
` _ Commonwealth of Massachusetts
fit
Division of Professional Licensure
Boar
of Ay
wilding Regulations and Standards
Cons
r � n Su r or
CS108817 Expires : 08/23/2022
t
ROBERT CA OUN
8 UPPER RIVER RD
SOUTH HADL Y MA 0107 r
Commissioner da-At '.
L
W Worker's Compensation and Employer's Liability Policy
AmGUARD Insurance Company - A Stock Co.
��!Berkshire Hathaway
Policy Number R2WC182010
� t G uARD Insurance Renewal of R2WC053509
4'A Companies NCCI No. [21873]
Policy Information Page (AR)
[1]Named Insured and Mailing Address Agency
GREEN COLLAR LLC AMHERST INSURANCE AGENCY INC
370 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, 2020 to September 23, 2021, 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-WC2003068
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 $ 21,496
Total Surcharges/Assessments $ $728.00
Total Estimated Cost $ $22,224.00
INTERNAL USE XX Page - 1 - Information Page
MGA : R2WC182010 WC 000001A
Date : 09/11/2020
MANOTE
Issuing Office: P.O. Box A-H, 39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.com