28-008 (2) 336 SYLVESTER RD BP-2021-1566
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:28-008 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED('c)NTRAC1 ORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2021-1566
Project# JS-2021-002596
Est.Cost: $732.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sq. ft.): 1361250.00 Owner: VANASSE STEPHEN F&BETTY JEAN
Zoning: Applicant: GREEN COLLAR LLC
AT: 336 SYLVESTER RD
Applicant Address: Phone: Insurance:
351 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON:6/30/2021 0:00:00
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 NORTHAMPT U VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signal
FeeType: Date Paid: Amount:
Building 6/30/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
De
oa�H�M_:;o., City of Northampton ``�l FO
#,.-;� Building Department
Y �
212MainStF -t `��/1j KINSULATION
tr:
.,,, _ Northam_ .' .,
pton, M4°t S 0
»;..+' phone 413 587 1240 Fax - r -1272��� ONLY pj, i,G
APPLICATION FOR INSULATION FOR A ONE OR TWo PA, ► DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
jam`O_ `JQSkQ` 4a Map A , Lot (70g Unit
.J� SUS
+� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
SA"'aR.I) Otago.<&o_ ' S(0 &Juo�•Ivr ((.
Name(Print) Current Mailing Ad ress:
LJ,S— Gar.- RS-/
Telephone I
Signature
2.2 Authorized Agent:
('•r ve r) CoIIc4f— 406 (c 1J,nr,h :: (0 SL )t;o'ilar iQrl
Name(Print) Current Mailing Addr&ss:
//2 r--0// —r _ t-t(y _ (-,A b- R Sfi r ,
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
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee 3/
4. Mechanical (HVAC) C
5 Fire Protection
6 Total = (1 +2 + 3 +4+ 5) • Check Number Z0.3
f� -(y�TThiis Section For Official Use Only
BuildingPermit Number: '✓g `dl' I -r `r Date
Issued:
Signature: /'� (/- -3 ) -' z(
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
• f
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: 12 ph C.G�1,o v Y1 C --
�/n� License Number
QQ-
8 u r 0-w e r \{�
Address Expiration Date
(/lg- 53.1- I Sri
Signature Telephone
9.Reoistered Home Improvement Contractor: Not Applicable ❑
Croeh C'rAloS I
Company Name Registration Number
S.10 A.).(Join S-4-• Soc�1L‘ \-tar)Lay, An 0/o 7S v 3 A//q_aa
Address Expiration Date
I I,fo gQ G(o on coups tv,A. Corn Telephone-N3-S5.1-I ar"7
SECTION 5-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 if No ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
t'v\*a\\ 3," c;b<r 0,o$5 10o1/44 `,,j k c QaSo t 1
l 1„ c;h Co.11,o,,,\ , 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.
IK oNn Co‘bnou►-\
Print Name
i/0/11
Signature of Owner/Agent Date
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
YH�M j.i
tag p °ti'• 5,5 :"s�
Massachusetts � y. f
g
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building J. csa
rT ' Northampton, MA 01060
ar
rsNh ,`‘o
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 am adjacent to such residence or building"be
done by registered contractors. j i
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: co,o.d u c z o.A soh / ti ak c< Est. Cost:
Address of Work: 3(0 cy lw,c.a Q r-
Date of Permit Application: L/its '
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 U/J I Gro.e h Cara r 1 N;1i
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
,fir-- E Massachusetts '`
f DEPARTMENT OF BUILDING INSPECTIONS , F
,y 212 Main Street •Municipal Building er 4,',
Northampton, MA 01060 s' "
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:
(Please print house number and street name)
Is to be disposed of at:
(1(1' 'h (e' c tt-i VN[\i- a s.-) S�c4K 1r c)l.y ,w4 016-7S
(Please print name and l cation 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.
YM M City of Northampton
s s'c,
Massachusetts
.;�
:%4 DEPARTMENT OF BUILDING INSPECTIONS 'y ti max'
212 Main Street • Municipal Building S ,Ss,.
Northampton, MA 01060 Sf'Y S'ON'^
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 3S1/4a 1uec er
Contractor
Name: (,c eel-. Cottc r
Address: S10 ,Jp,Anh
City, State: Soul. \\cAal ey MA
Phone: - S31- k g n
Property Owner
Name: Sa hetsS-e.
Address: 3 Co Sulugszl"r Qtl
City, State: ATh i kc,MPte r M A-
I, C nl/a (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 7/
Date
Co//GPI
Docusign envelope ID: B18AC5E0-E804-4145-94BA-FEB443F67206
Permit Authorization
1
mass save Form
Site ID: 4233492 Customer: STEPHEN VANASSE
Stephen vanasse
I, , owner of the property located at:
(Owner's Name,printed)
336 Sylvester 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. p-pocuSigned by:
SitrUAA. UatA A.SSt.
Owner's Signature: -F7EFCD78126C49F
5/11/2021
Date:
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:
Page 1 of 1 For Office Use Crl y
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 ( 5 4. ❑ I am a general contractor and I 6. El 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 10.0 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' 13.1X 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: 3*S Lo S./1 u e S1 o r (j City/State/Zip:;,:,-t l��.� ('l�tir ,t,t4 61c0,
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: '�7.✓�-wc Date: 6/1(../
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#:
� Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Reg ! i t
ulations an . - = � � ''=--
z
Constructiôn'Supervisor
CS - 108817 Expires :00,
0812312022
ROBERT CALHOUN ,-,,,
8 UPPER RIVER RD
Y MA 0107r
SOUTH HADL
Conn IssIoner �. ....
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
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature
N 'A Worker's Compensation and Employer's Liability Policy
/Berksh ire HathawayAmGUARD Insurance Company - A Stock Co.
�V' Policy Number R2WC182010
ri' GuARD 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-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)
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