25C-183 (5) BP-2022-0082
2 HIGHLAND AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-183-001 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-2022-0082 PERMISSIONISHEREBYGRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 4395 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2022
Use Group: Owner: MARKET STREET RENTALS LLC
Lot Size(sq.ft.)
Zoning: URC Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570NEWTON ST (413)532-1817 R2WCI18201.0
SOUTH HADLEY, MA 01075
ISSUED ON:01/25/2022
TO PERFORM THE FOLLOWING WORK:
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: I .>2cp'
Fees Paid: S65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massa4huse
�, Board of Building Regulations an Sta ards FOR
Massachusetts State Building Cod 780 CM AN 2 4 MUNICIPALITY
2022 ( USE
Building Permit Application To Construct, Repai Ren avate Or Demolish a ;Revised Mar 2011
One-or Two-Family Dwel i'ng DFPT of run r,,;r,ire= . •
This Section For Official Usg.Onl `- " :
Building Permit Number: 4 Q 0-- iv; Date Applied:
Building Official(Print Name) Signature Pig Dat
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Nu7o 3 rs
LI H'jh hut d Atte A 6-C,
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 Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private El Municipal Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re ord: n
Vallty a-Q C LL( illOr4h0t1uet-on , MixOAOtop
Name(Print) City,State,ZIP
LI kilhl�d (iv�c. u13.5$y-73o8
No.and S et 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 CZ Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
InSta.Qt I m;/ ID a 94- y afOr barn2.2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) ,
1.Building $ q, 3 q 3- 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: $
Check No.14 Ci.:V Check AmounV Cash Amount:
6.Total Project Cost: $ (/ 3 9 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) 1814 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 Ei0 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' is application is d accurate to the best of my knowledge and understanding.
Print Owner's or Authoriz 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"
Permit Authorization
•
mass save Form
Site ID: 4131886 Customer: Valley Rental Company LLC
Valley Rental Company LLC
I, , owner of the property located at:
(Owner's Name,printed)
4 Highland Ave Apt. 4B Northampton, MA 01060
(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.
Owner's Signature: peg ing reuhgles:cotu
Date: 01 / 06 / 2022
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
C7reer1 Ls l�Q�, LLC /,/qaa
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only
City of Northampton
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Massachusetts r . c�`<
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DEPARTMENT OF BUILDING INSPECTIONS
yv e`z
212 Main Street •Municipal Building b O
Northampton, MA 01060 rSfrJ ar,\\
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:
LI Hi5hlam' AvC
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Q i L SoN)cQ S - 5" urn e 01 •
Company Name and Address)
Signature of it 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
=r 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
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' 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.❑ 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.
tContractors 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 18Q2,0/10 Expiration Date: 9/23/2022
I�
Job Site Address: O 6ura.W&' City/State/Zip:0)1,l cor i n14'
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#:
Yi-e romnr,y0, i 0/ ei4e.4a0,4(.4eexi.
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, M sa�p�husetts 02118
Home Improvem t Cbptractor Registration
Type: LLC
trI l 7- Registration: 181415
GREEN COLLAR LLC. `"3; =` W
ice, a r Expiration: 03/31/2023
- 570 NEWTON ST ("f "._ b u
SOUTH HADLEY,MA 01075 RI �. N o
•- _-_ �t
V�
_w • Update Address and Return Card.
SCA 1 0 20M-05/17 ...1 p p X p
Afe
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only '1
T,� E:LLC before the expiration date. If found return to:
Rea lit
i'3tlo Expiration Office of Consumer Affairs and Business Regulation
1314 --=:=3 03/31/2023 1000 Washington Street -Suite 710
GREEN COLD />A Boston,MA 02118 •
STEVEN ECKMA it
� — // /�
570 NEWTON ST, „y< �(,,„.. 'CG.4.k
SOUTH HADI_EY.MAN- - '5 Not valid without signature
•Undersecretary
•
Commonwealth of Massachusetts
- VI Division of Professional Licensure
. Board of Building Regulations and Standards .
Cons fVkj Jisor
CS-108817 ,' { ; !. :' ;.f pires:08/23/2022 '
4 ROBERT CAF'1OU 41
ROI ; O ,
SOUTH HADL@• yY MA 15 i)1',. -'. `
30 • .
US:3p°
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Commissioner d,•t K. YE,nL,Q.u..
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