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24A-130 (7) BP-2022-0687 33 PROSPECT AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-I30-001 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-2022-0687 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 4433 GREEN COLLAR LLC 108817 Const.Class: Exp.Date:08/31/2022 Use Group: Owner: KABAKOW BENJAMIN MARA & LAURIE Lot Size (sq.ft.) Zoning: URA Applicant: GREEN COLLAR LLC Applicant Address Phone: Insurance: 570 NEWTON ST (413)532-1817 R2WCI 182010 SOUTH HADLEY, MA 01075 ISSUED ON:06/10/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ER I ZATI 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: I41 V t >2 CP1 • it Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner q_CE I ' _ DThe ommonwealth of Massachusetts .._�_ FOR Bo rd o Building Regulations and Standards MUNICIPALITY JUN - 9 2022 M sac setts State Building Code,780 CMR USE Building Permit ppli ation To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 nFP ()F One-or Two-Family Dwelling I ,�,-4- 444t fNt�INc cc• M" !`" naA ct6 S This Section For Official Use Only Building Permit Number: 1Z2 P- '4h it b 7 Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers ___,3 _ Peas peck Ae 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name( rint) City,State,ZIP 33 PrD c,f- *vc 4242 -b(o( -9,z 3 z. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 1$ Specify:Insulation/Weatherization Brief Description of Proposed Work2: Insulation/Weatherization It 'I " cakaut A_ 14,73 sbN- Luaus SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 7, 213 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 No616 Check Amoun l-1 Cash Amount: 6.Total Project Cost: $ ' y 3 3 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 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 W 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 'cation is true and accurate to the best of my knowledge and understanding. rint 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" Alek Permit Authorization mass save Form Site ID: 4490387 Customer: MARA BENJAMIN Mara Benjamin I, , owner of the property located at: (Owner's Name,printed) 33 Prospect Ave 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: Mara Bela Date: 05 / 19 / 2022 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Partic' ' g Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street 4 ti l Boston,MA 02111 4 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name(Business/Organization/Individual): Green Collar, I,I,C 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 IS 4. 0 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. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ 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 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.®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. :Contractors 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 W C 182010 Expiration Date: 9/23/2022 Job Site Address: 413 &Spec" �r^�h s� . City/State/Zip: 4/`"r h'• . " Ark 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#: A7�D® CERTIFICATE OF LIABILITY INSURANCE DATE 02 02 YY) 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 PHONE (413)253-5555 FAX (A1C,No): (413)256-8354 -JA/C.No.Exit: 20 Gatehouse Rd. E-MAIL dsawicki@nathanagencies.com ADDRESS: P.O.Box 48 INSURER(S)AFFORDING COVERAGE NAIC 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 AD• SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENT EU S 1,000,000 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S 100,000 MED EXP(Any one person) s excluded — A 771BG0552101 10/25/2021 10/25/2022 PERSONAL aADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE 5 2,000,000 POLICY n JECaT 0 LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S B AUTOS x SCHEDULED PCA0100300842 08/27/2021 08/27/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S X AUTOS ONLY X AUTOS ONLY (Per accident) 5 X UMBRELLA UAB '_ OCCUR EACH OCCURRENCE s 2,000,000 C EXCESS LIAB CLAIMS-MADE XBS014069 10/25/2021 10/25/2022 AGGREGATE S 2,000,000 DED I RETENTION S S WORKERS COMPENSATION (PER OTH- AND EMPLOYERS'UABIUTY Y/N I STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDEDri (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/VEHICLES (ACORD 101,Addttonal Remarks Schedule,may be attached If mere space 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 N V. c .lw cadv ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton '�v+ter 19Z6 ✓KN1MY .rk. oa r04 �5.5 Sic //1' � Massachusetts ti4, mac.. H „, t t DEPARTMENT OF BUILDING INSPECTIONS .. °s ' 212 Main Street • Municipal Building S ,, �'�' Northampton, MA 01060 �nN MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 33 Trbspec e S -f- Contractor Name: Cl\v- .0 Col ar , tLC Address: c7O1 'e1Alrb S-� City, State: JU n RoclUi Phone: Li f 3 "530/ • 1$1 1 Property Owner Name: IL IV okra. nen3 aryl yl vv, Address: AI r.3 'vS XiA- St- City, State: !, d(- ha .ry h , NI6A- I, Qwc.Qy\ Co( I ow) cc,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 Date (0 i 17 -k6)-