37-083-018 BP-2022-0798
266 GROVE ST UNIT I x COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
37-083-018 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-2022-0798 PERMISSION IS HEREBY GRANTED TO:
Project# 2022 INSUALTION Contractor: License:
Est. Cost: 1356 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2022
Use Group: Owner: COOK PAMELA A
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:07/08/2022
•
TO PERFORM THE FOLLOWING WORK:
INSTALL CELLULOSE INSULATION IN ATTIC
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:
. • r . . T
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildins Commissioner
0 i
. _ The Commonwealth of Massachusetts
, 14Board of Building Regulations and Standards FOR
b� Massachusetts State Building Code,780 CMR MUNICIPALITY
� USE
i B 'I'di g Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
m
One-or Two-Family Dwelling
=' N-3 MI
om; This Section For Official Use Only
:uildiiiiiPermi rNumber: 2-drL2-- Date Applied: 07/0(o '20 - -
w,,,) �5S I -Zoz2
Building Official(Print Name) Signature Date
- SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
d(0(y C—i V ovt. S * ((A-1 t 1( 37-5S 3-b( g
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
to R►3
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>o- . Coo )OPnct t v h ,M(%--
Name(Print) City,State,ZIP
,1ov-c_ Si- L`,n,,1-1., 1 go 3 d3o 4 a-77
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 tgl Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
)(S -1 '` CCULAA 0 fe TO 4O sti—i- OhC +i'( )
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ i 13 S 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 No.6)el to Check Amountf(a.b,'Cash Amount:
6.Total Project Cost: $ If 3 5c 0 Paid in Full 0 Outstanding Balance Due:
t
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) 3/31/2023
Green Collar,LLC 181415
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 IS] 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: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
containe in this application is true and accurate to the best of my knowledge and understanding.
Print 0 ' ut orized 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"
GREE
€1.
COLLAR
Permit Authorization Form
Pam Cook
(Owner's Name)
Owner of the property located at:
266 Grove St Unit 18
(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.
Jam Cask
(Owner's Signature)
6/2U/22
(Date)
351 Newton St. Unit B South Hadley,MA 01075 Phone.413.532 . 1£1;' Email: support@greencollarma.com
The Commonwealth of Massachusetts
/ Department of Industrial Accidents
P Office of Investigations
600 Washington Street
:J 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 /7 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'
[No workers'comp.insurance comp.insurance.: 9" U 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
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.
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 um an employer that is providing workers'compensation insurance for my employees. Be%w is the polio'and joh site
information.
Insurance Company Name: AmGUARD Insurance Company - A Stock Co.
Policy#or Self-ins.Lic.r__ #: R2 WC 182010 Expiration Date: 9/23/2022
Job Site Address: a l9 W (jtb()vP '- l' City/State/Zip: Nor-r4'cu\s a'Uh i C
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#:
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: a co(Q C 13Q-t_ 8
The debris will be transported by: G yea Co (0-r .
The debris will be received by: 4 tl, C
Building permit number:
Name of Permit Applicant o h& CwJ k tx-h
igq
Date Signature of Permit Applicant