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38A-038 (3)
BP-2022-0081 50 CHAPEL ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38A-038-001 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-2022-0081 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 2525 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: ADB-2 PROPERTIES LLC Lot Size (sq.ft.) Zoning: URB Applicant: GREEN COLLAR LLC Applicant Address Phone: Insurance: 570 NEWTON ST (413)532-1817 R2WCI 182010 SOUTH HADLEY, MA 01075 ISSUED ON:01/25/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ER I 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: e: . .542 cfr Fees Paid: $65.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1 , The Commonwealth of Massachusett I AA N ? - OR Board of Building Regulations and Stand rds 4 ?O22 W Massachusetts State Building Code,1780 MR CIPALITY iUSE Building Permit Application To Construct,Repair, Reno ;p?vp.roN A TIC Ns evistd Mar 2011 One-or Two-Family Dwelling ,.�so_ This Section For Official Use Only Building Permit Number: 05"; ' 9/ Date Applied: I c97 aa Building Official(Print Name) Signature Da SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Ass s rs Map&Parcel N s SO Chc e/ S+ 3 g� �� 1.1a 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 Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: At an --W6enuickid Noy' ct.er°r,c'M Name(Print) City,State,ZIP 50 ChrAp24 Si- y14 -531 -5109 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 ta Specify:Insulation/Weatherization Brief Description of Proposed Work2: Insulation/Weatherization 26) Air 3.ec.,(Anok 3) Ven+ n S SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 2 i 5 2 C 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 Fee /'6 Check No. 11 heck Amount 1.1 Cash Amount: 6.Total Project Cost: $ o:, 5 2 5 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 35,000 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 HIC Green Collar,LLC Registration 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 ffa No ❑ 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 appli n is true and accurate to the best of my knowledge and understanding. Print Owner's or Aut rized 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 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" COLLARIIG EN E Permit Authorization Form 1, (41ckr, &(-Y-121 (Owner's Name) Owner of the property located at: ViCkPgS . (Property Address) t (r14- (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. (Owner's Signature) 1 1(3 (Date) 351 NeMon Sf B Se,On tiad'ay MA 4) u( None 413 n12 1817 Er1a4 stipporiggreencoltarma 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 employees(full and/or part-time).* have hired the sub contractors 6. ❑ New construction 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' [No workers' comp. insurance comp. insurance. 9. ❑ Building addition 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.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.© Otherinsulation/Weatherization comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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�C182010 Expiration Date: 9/23/2022 Job Site Address: 50 Chp p€P Wit' City/State/Zip:N }A,►n 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 perjuty 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#: 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: 1O Chap SI-- The debris will be transported by: CYY1 1 0 liar The debris will be received by: Grec 0 Co 1 lot r Building permit number: Name of Permit Applicant `- ahAL V\ 0 II3 / L Date Signature of Permit Applicant yz ro,./.gio. ,,,,,,,,4. Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, M slap,husetts 02118 Home Improvem t ttntractor Registration Type: LLC 4 , i Registration: 181415 GREEN COLLAR LLC. icIl • 7' : .:` st Expiration: 03/31/2023 570 NEWTON ST PI • ----' SOUTH HADLEY,MA 01075 + >, ~i_,,, Update Address and Return Card. SCA 1 8 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only T�x E:LLC before the expiration date. If found return to: Rea1sti'Mlo 1 Expiration Office of Consumer Affairs and Business Regulation 1 03/31/2023 1000 Washington Street Suite 710 GREEN COLD Boston,MA 02118 IA't.-, , . ) . k ,..: STEVEN ECKM ' 570 NEWTON ST',.Nki/ 4 SOUTH HADI_EY MA ?5 - Not valid without signature Undersecretary • 'T Commonwealth,.of Massachusetts t Division of Professional Licensure - Board of Building Regulations and Standards . Cons f IkEkal isor r • • CS-108817 �' "' spires 08/23/2022 ' 4 ROBERT CAF, f'OU(� .40 8 UPPER RI R t1�'i1'It ,' p SOUTH HADL9Y NFA ,'/: ' . *,, V r' / 4 O T Commissioner d'i'. K. �vnc�.a� 0