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24A-162 (5) BP-2022-0601 333 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-162-001 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 Penn it # BP-2022-0601 PERMISSION IS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 1658 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: ANACLETO SOBRAL,FILIPE & HEIDI ELIZABETH Lot Size (sq.ft.) Zoning: URA Applicant: GREEN COLLAR LLC. Applicant Address Phone: Insurance: 570 NEWTON ST (413)532-1817 R2WCI182010 SOUTH HADLEY, MA 01075 ISSUED ON:05/27/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/W EATH ER I Z ATI 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: 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 0 • • >2 . Fees Paid: S65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner a--,HA,p; „ City of Northampton '}( -_ Dep O Building Department] — r'� , tlt212 Main Street 1 INSULA ,, Room 100 AY2+ .° f Northampton, MA 01060 6 20 \<. '' s^ 2 ONLY phone 413-587-1240 Fax 41,��. RTHAMPTON�AASPE CdNS APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT This section to be completed by office 1.1 Property�A}ddress: -���/� 333 1 J�cr S+ Map /�"'�/ Lot I(1- Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I,p� Spore -+CVYAibeAkA 2)3 3 ?r>,;p'cA-S-�- Name(Print) Current Mailing Address: See cv( '-Q" 31�► - qua - �q� Telephone Signature 2.2 Authorized Agent: ROsisecr-4- 51° , (30JOi 624 , (V�t Name(Print) Current Mailing Address: U 53a -1Y I"l Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1)r 6 5g (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 60/7 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) 1 r l0 S$ Check Number Ci S This Section For Official Use Only Building Permit Number: f'�JP- d-(MO" DateIssued: Signature: 5 - 27 - 20ZZ Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: (>hp(- Catr0.1-r\ CS .- i V,ro 1 1 510 License Number "441fr S-` Sct \ao1ki-P).4 ,mck- '1�3 I d)--- Address Expiration Date xo--it ....-. y�3 -53�-\�'�1 Signature __ Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Gin C6,((kr Lt-C 1' l H I S Company Name Registration Number PO N•euJnr Z\--. Sa tad rV- 313' ` a Address Expiration Date Telephone I' -S3a -1611 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 No ❑ Brief Description of Proposed Work 11 lo_Sfi a,(,( ( -C't'e ckS " abet' C(3-t�'1_ON..v __ , 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. C Print Na„..me �:x� 51 ICI I a,a-- 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 DocuSign Envelope ID:2A18ABAE-C8CA-4AE9-B28F-6853ED5A94DE RISE ENGINEERING" OWNER AUTHORIZATION FORM I Filipe Sobral (Owner's Name) owner of the property located at: 333 Prospect Street (Property Address) Northampton, MA 01060 (Property Address) hereby authorize O CAI ICir, LE C 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. r—DocuSipned by: Ow�i 6NSs5'4E, hhtVre 2/17/2022 i 7:45 AM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com _ City of Northampton /?. ti'� - c'/'. Jr•►'r Massachusetts ��� -- {e ' ` ;, 4 1 � .'Tj DEPARTMENT OF BUILDING INSPECTIONS , 1i ", "w ^� 212 Main Street • Municipal Building A-J ci:a + t rr' Northampton, MA 01060 fs� ���.�Z+', 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 pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeownerregistered. has contracted with a corporation or LLC, that entity must he n Type of Work: 1 aS lO(tOjea.“142,62S3-40(\ Est. Cost: 1(C058" Address of Work: 3 (-40S peat- Sf-. Date of Permit Application: 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: 51 la Ctres.,6Cal(41r,LLC 18I LI I5" 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 4O SNS,.. r/C , Massachusetts A.�_ yl DEPARTMENT OF BUILDING INSPECTIONS x 212 Main Street •Municipal Building .? . � > Northampton, MA 01060 •PS'NFI 3D\`r`�'" 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: 533 opcc+ 5-±-- (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: (Company Name and Address) Signatur 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. .,:--- City of Northampton i o,ti s s - s c Massachusetts �° e*c; a, ii a� f* T �9 f DEPARTMENT OF BUILDING INSPECTIONS y \� ��,��� � 1 212 Main Street • Municipal Building J��� 1�� -4 "'` Northampton, MA 01060 d� ‘ MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 33 '%us pe ot S + Contractor Name: �l t-e en Col �a.(' r Lc._C Address: 5-1 0 N-e r` S''- City, State: :X.>.--k.4ex E-k-ad\eut i f\k _ Phone: (--k13 "S a-- l 81 ^l Property Owner Name: 1--- 1 l )pe. Sobr Address: 3 33 Rr 5 ix c S 4 City, State: i\)0 1 MA I, Grwnl (tar, Lc. C (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 .._.e.i2. Date Sl\c12-a, The Commonwealth of Massachusetts Department of Industrial Accidents * '= Office of Investigations / 600 Washington Street ',. 7 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 15 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.t required.] 5. ❑ We are a corporation and its 10.111 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.[X1 Othetinsulation/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.#: R2WC182010 Expiration Date: 9/23/2022 Job Site Address: 333 qa6ceot Sf. City/State/Zip: N -4;u ri' '� 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#: A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYVY) 1 o/z7/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Denise Sawicki NAME: Amherst Insurance Agency Inc PAHO Nu ExIt; (413)253-5555 AX( No): (413)256-8354 20 Gatehouse Rd. EMAIL dsawicki@nathanagencies.com ADDRESS: P.O.Box 48 INSURER(S)AFFORDING COVERAGE NAIC 0 Amherst MA 01002 INSURER A: CRC Group INSURED INSURER B: Preferred Mutual 15024 Green Collar LLC INSURER C: Scottsdale Insurance Company 570 Newton Street INSURER D: INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21102703683 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME°ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. tNSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVp POLICY NUMBER (MM/OD/YYYY) `(MM/DD/YYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 TO RENIED CLAIMS-MADE X OCCUR PRAMA MISES(Ea occurrence) S 100,000 MED EXP(Arty one person) S excluded A 771BG0552101 10/25/2021 10/25/2022 PERSONAL&ADV INJURY S 1,000,000 GEM.AGGREGATE LIMIT APPUESPER: GENERAL AGGREGATE S 2,000,000 POLICY ri EC7 n LOG PRODUCTS-COMP/OP AGG S 2,000,000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED PCA0100300842 08/27/2021 08/27/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED Nye NON-OWNED PROPERTY DAMAGE S _ AUTOS ONLY _ AUTOS ONLY (Per accident) S X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LMB CLAIMS MADE XBS014069 10/25/2021 10/25/2022 AGGREGATE S 2.000,000 DED RETENTION S _ S WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE , NIA E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L.DISEASE-BA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S — - $1,000,000 Pollution Coverage A G28375748001 01/20/2022 10/25/2022 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddttIonal Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD