23D-023 (13) BP-2022-0444
496 ELM ST COMMONWEALTH OF MASS £ CHUSETTS
Map:Block:Lot:
23D-023-00I CITY OF NORTHAMP ION
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTER D D CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY F ND (MGL c.142A)
BUILDING PE MIT
Permit# BP-2022-0444 PERMISSIONIS REBYGRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 569 GREEN COLLAR LLC 108817
Const.Class: Exp. Date:08/31/2022
Use Group: Owner: ELIZABETH IUBINSKY JONATHAN &
Lot Size (sq.ft.)
Zoning: URB Applicant: GREEN COL •R LLC
Applicant Address Phone: Insurance:
570NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON:05/13/2022
TO PERFORM THE FOLLO WING WORK:
INSULATION/WEATH ER IZATION
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHA PTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: Q
. CPI .
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413) '87-1272
Office of the Building Commissioner
t • C 1'4Lj fro - !ln .'L' 5_1 /
The Commonwealth of Massachusetts
Board of Building Regulations and Standar* p MUNICIPALITYOR
F
Massachusetts State Building Code, 780 CM a USE
Building Permit Application To Construct,Repair, Renovate Or DeA3h a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only c -
Building Permit Number: GP— ?'y / Date Applied: e/i°s
1/2 5-1 3 2Ozz
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
4q(, Elm S+
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 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'of Record:
Name(Print) ■ w , b ��� City,State,ZIP i
4942 c(n• S q13-709- Wig
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) ❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other Da Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
;?-. Aikoerepss to go -F— h7tc>erner
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1 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 Fees:
its
Check No.t O Check Amours. Cash Amount:
6.Total Project Cost: $ S(p 9 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 Lnrestricted(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 R
HIC 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 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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized 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"
The Commonwealth of Massachusetts
•
Department of Industrial Accidents
, .—Iiim tia, Office of Investigations
r4
}? 600 Washington Street
AI
- 0� Boston,MA 02111
=—' �,,07 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 thppropriate box: Type of project(required):
1.® I am a employer with 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 11.0 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.
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 numbed.
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.#: /- R2WC182010 Expiration Date: y 9/23/2022
Job Site Address:qq(0 Elm Si- City/State/Zip: M14' otbfl 1 M-0.`
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#:
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Ma.sta.qhusetts 02118
Home Improvement Contractor Registration
Type: LLC
�i :�,tr, Registration: 181415
GREEN COLLAR LLC. { � - t`( -
��,,� � -- ,� Expiration: 03/31/2023
- 570 NEWTON ST r°# '; __ - u
SOUTH HADLEY,MA 01075 l i N ' "'-
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0
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-� tii
a�k ..„-rs'
`�^ 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
Tit, LLC before the expiration date. If found return to:
Realstratlo Expiration Office of Consumer Affairs and Business Regulation
B I14 c -. 03/31/2023 1000 Washington Street -Suite 710
GREEN COLLI #; r}n Boston,MA 02118 •
cl aicr `'r
.. ,.:
,,,
:.
STEVEN ECKM
570 NEWTON ST'. -� /,�/ �' '`°YCG
SOUTI�I HADLEY,MA_ ?5 - Not valid without signature
Undersecretary
f " Commonwealth.of Massachusetts
- t Division of Professional Licensure
. e Board of Building Regulations and Standards .
Consk0t M $ visor . '
CS-108817 .y�' ,,,I� "`` ;. Aires:08/23/2022 - ••
•
ROBERT CA(,�AOU -401
8 UPPER Mir RD "ibl , p ,
SOUTH HADLRY MAC 1 ir_^� '. .'
Commissioner d, c f Emd.ca_.
o
.
DocuSign Envelope ID:84972AF3-DOAA-4Al2-932A-0C60A9285B55
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
Jonathan Dubinsky
(Owner's Name)
owner of the property located at:
496 Elm Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize L-1,2f"\ ({a 1 lcjv ,LCC
Subcontractor(to be filled in by office)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
p-DocuSigned by:
\\
OrtiffigipnViMilre
3/18/2022 1 4:40 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 ( Canton, MA 02021 f 339-502-6335
www.RlSEengineering.com
City of Northampton
Massachusetts * r;
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 s.fh7)0
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 496 Elm ST
Contractor Green Collar,LLC
Name:
Address: 570 Newton St
South Hadley
City, State:
413-532-1817
Phone:
Property Owner Jonathan Dubinsky
Name:
Address: 496 Elm ST
City, State: Northampton, Ma
I, Green Collar,LLC (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 Rob Calhoun
Date 5/13/22