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25C-244 (5)
BP-2022-0587 249 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25C-244-001 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-2022-0587 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est.Cost: 797 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: BURTRAM SHAMSIDEEN, Lot Size (sq.ft.) Zoning: URB Applicant: GREEN COLLAR LLC Applicant Address Phone: Insurance: 570 NEWTON ST (413)532-1817 R2WCI182010 SOUTH HADLEY, MA 01075 ISSUED ON:06/01/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/W E ATH E R I Z AT I 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: Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner . k)&u w r.- Otio i - +- + -30- he ommonwealth of Massachusetts oa d of uilding Regulations and Standards FOR MAY 2 4 2C2 as achuetts State Building Code,780 CMR MUNICIPALITY USE B ' ' • ication To Construct,Repair, Renovate Or Demolish a Revised Mar 201 1 r+FPT.OF WILDING INSPECTI ,,,,r1THAmrToN_,no,o,oso ___ One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:6r `..2- &2 7 Date Applied: 6.--o,N /XosS / , te-1-ZOZZ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers uq i3ndg�. Si-. a 5�. a y� 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 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: t rtrarn S11o44 si de.e n IJOt w ptai ,rna a IOW Name(Print) City,State,ZIP 3qq F3ndgc s4 . qI3-a7o•0-73 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(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 Ca Specify:Insulation/Weatherization Brief Description of Proposed Work2: Insulation/Weatherization 1nS4aiU 'K-l9 -Pi'be4-9/asj local- -to bPs6f' bajeme sr lhSvJ dian itinta :c- (v X Siy-t"• SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ -7 q 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 $ Total All Fees: $ Suppression) l9 ��j Check No.5 07D Check Amount:'1 Cash Amount: 6.Total Project Cost: $ 7v 7 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 108817 8/23/2022 Robert Calhoun License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 390 Newton St. Type Description No.and Street 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 Green Collar,LLC HIC Registration Number Expiration Date HIC Comnanv 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.g 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 W 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:OWNER1 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 applic ' 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" RISE ENGINEERING" OWNER AUTHORIZATION FORM Burtram Shamsideen (Owner's Name) owner of the property located at: 249 Bridge Street (Property Address) Northampton, MA 01060 (Property Address) hereby authorize 6tie/1 Ce ll'av &LC 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. Owner's Signature 11 ( I ( )S4 k \r. Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com 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 if 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. 0 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. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions m self. [No workers' comp. right of exemption per MGL yp 1 12.0 Roof repairs insurance required.]t c. 152, § (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. 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 h Job Site Address: 07 / 'Bad?, St. City/State/Zip:J)(X' 1AA.4 h ttuGL Attach a copy of the workers'compensation policy declaration page(showi nd 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 9 OD® CERTIFICATE OF LIABILITY INSURANCE DATE 0 7/27/202 m 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(les)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 PHONE (413)253-5555 FAX (413)256-8354 (A/C.No.EMI: (A/C,No): 20 Gatehouse Rd. EMAIL dsawicki@nathanagencies.com ADDRESS: P.O.Box 48 INSURER(S)AFFORDING COVERAGE NAIL o Amherst MA 01002 INSURERA: CRC Group INSURED INSURERS: 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 NAMED 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. INSR ADOL-SUBR PO-UCY EFF POLICY EXP LTR TYPE OF INSURANCE J.NS° Wyp POUCY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE f 1,000,000 DAMAGE TO RENT CLAIMS-MADE a OCCUR PREMISES(Ea occuErrence)D $ 100,000 MED EXP(A one person) S excluded ny A 771BG0552101 10/25/2021 10/25/2022 PERSONAL EL ADV INJURY f 1,000,000 GEN'LAGGREGATE UMITAPPUES PER. GENERAL AGGREGATE S 2,000,000 POLICY JECTT n LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE LABILITY 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 XHIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per acddont) S X UMBRELLA UAB OCCUR EACH OCCURRENCE S 2,000,000 C EXCESS LAB CLAIMS-MADE XBS014069 10/25/2021 10/25/2022 AGGREGATE S 2,000,000 DED I RETENTION S S WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'UABIUTY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT S $1,000,000 Pollution Coverage A G28375748001 01/20/2022 10/25/2022 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Its 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. AUTHOR2ED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD --..,, City of Northampton .o, S`5";.; SPC Massachusetts ,f� 4.- r`'; L' .A w s ., 4 DEPARTMENT OF BUILDING INSPECTIONS It 212 Main Street • Municipal Buildi � ,;:ng v� a Northampton, MA 01060 4.4 mil* MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: a9(3 `Zrioy S+ Contractor Name: J n Collar r L L C L -'(ray Address: t tV "ibR S 1- City, State: MCS*CX(1.m . Ma- Phone: 1-it 3 -S3a - t g i l Property Owner � Name: V-1—41e"0-- S M elak YsS% 604.n Address: aqok (660 & 4- City. State: I JO ,! n + Ma I. Gre.efk Cei6r ,1 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. ...._,(16 Contractor signature Date C/O /r /ca- a-- i