30B-013 (8) BP-2022-0080
30 NORWOOD AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-013-001 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-2022-0080 PERMISSION'S HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 1949 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2022
Use Group: Owner: PARZYBOK EZRA J&BROOKSLEY E WILLIAMS
Lot Size (sq.ft.)
Zoning: URB Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON:01/25/2022
TO PERFORM THE FOLLOWING WORK:
INSULATI ON/WEATHERIZATI 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: , 51-1,1
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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ri '
The Commonwealth of Massachusetts ,-..,,._ .-
W Board of Building Regulations and Standards i F R
Massachusetts State Building Code,780 CMR 2 4 I IPALITY
2G22 SE
Building Permit Application To Construct,Repair, Renovate_Or Demolish a vise Mar 2011
One-or Two-Family Dwelling i_F,;,F n;_
This Section For Official Use Only �"' ^A mo,;0
Building Permit Number: ICY' 2, 'I O Date Appli-d:
*/(99`•1Building Official(Print Name) Signature e
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3 0 N'OrUx'�d Ave 30ig• 073
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 0 Private CI Municipal_ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Cn.i o, Swei f ier • NOr4farripi-o r\ ,M.1k
Name(Pring City,State,ZIP
36 I at& Ave Lila -lae-1y1s
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 1,4l Specify:Insulation/Weatherization
Brief Description of Proposed Work': Insulation/Weatherization
►nsi-oJu g-)3 -goer16.33 ere Cola)
pbal;c, vapor kz IYi r (no
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ ( qq 9 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire /
Suppression) $ Total All F /�
Check No. / i aft
Check Amount: Cash Amount:
6.Total Project Cost: $ ), Ci ii p 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 Comvanv 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 ❑ 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' this ap ' ion is true and accurate to the best of my knowledge and understanding.
Iala�
Print Owner's or A 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"
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: 30 Norwood Ave
The debris will be transported by: Grp CAA (ar
The debris will be received by: C p) w l
Building permit number:
Name of Permit Applicant Rob Ca-4 out.n
1411-24
Date Signature of Permit Applicant
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 /.s 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.❑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' 13.1Xl 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.
1Contractors 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.#: R2 WC 182010 Expiration Date: 9/23/2022
Job Site Address: 50 NOrLOOOd C City/State/Zip:'(V6 ho
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 correcx
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#:
vim20- 1
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Ma*aphusetts 02118
Home ImprovemWOntractor Registration
, ,....,.15„.„........ Type: LLC
00 l'i----t----7547 ,--i--• x . Registration: 181415
GREEN COLLAR LLC. gi FEitF.7*3— r 7.2.:',—..-- L,L,I. Expiration: 03/31/2023
- 570 NEWTON ST i ::::7-7:•-,-.7.-1,4. .f...._-_' :...-;—• v.1
i I i V--....7:--'4,.
SOUTH HADLEY,MA 01075
"', 7""—:::.:f.r),.,
• —C_...,-- Update Address and Return Card.
SCA 1 0 20M-05/17
..9Z, Foriv-rweie;Aead16/.//bamadreaeat :
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Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only .N.
9. t WE:LLC before the expiration date. If found return to:
Re li iiiti Expiration Office of Consumer Affairs and Business Regulation ..,
.2= 03/31/2023 1000 Washington Street -Suite 710
GREEN COL
I Boston,MA 02118
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STEVEN ECKM k //
::;:-/47 a SOUTIA HADLEY,VA-1417g . - Not valid without signature 1.
Undersecretary .
Commonwealth.of Massachusetts
Division of Profe,ssional Licensure
. 11) Board of Building Regulations and Standards
Cons visor
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CS-108817 ,, ' : ,.'' : 1 ; EOkres:08/23/2022 '
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ROBERT CAO1OU `-. '4
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8 UPPER RIVER - i.irtd I • 0 >
SOUTH HADLRY 6/1..fit ,p,'_'•
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`VOtq'illP ,.
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%. .• Commissioner ekcia K. YEknile.(.„
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GREEN
COLLAR
Permit Authorization Form
Craig Sweitzer
(Owner's Name)
Owner of the property located at:
30 Norwood Ave
(Property Address)
Northampton, Ma
(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.
Cxaig Swett/wt.
(Owner's Signature)
(Date)
351 Newton St. Unit B South Hadley,MA 01075 Phone:413.532. 1817 Email: support@greencollarma.com