44-070 (4) BP-2022-0981
32 FAIRWAY DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
44-070-001 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-2022-0981 PERMISSION IS HEREBY GRANT TO:
Project# INSULATION Contractor: License:
Est. Cost: GREEN COLLAR LLC 108817
Const.Class: Exp. Date:08/31/2022
Use Group: Owner: TERESA KELLOGG CHRISTOPHER S &
Lot Size (sq.ft.)
Zoning: WSP Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON:08/15/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ER IZATI 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 VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I 7-0
r
Fees Paid: $65.00
212 Maui Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachu etts %CE" J x
Board of Building Regulations and and ds ,, R
\{" Massachusetts State Building Code, 80 UNI PALITY
�4UG 1a SE
Building Permit Application To Construct, Repair Ren vate Or Demli20 evise Mar 2011
One-or Two-Family Dwel ing AT o,
n�:
T is Section For Official Use-"On 7 qM Toc nucbc,..
Building Permit Number: br- ` 0 i Date Applied: N' .2o��o Ns
Zoii.-S(Koss ei 7 q-)5-zozz
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 PKop rty�oddyresss::
De
1.1a Isaccepted1.2 Ass s rs Map& Parcel Num
Is this an V 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 Own Record:
___ tescr._ teJ kt Vo n I A^CL
Name(Print) City,State,ZIP
3a 2113 - S5a -" K
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 I$1 Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
krS3c U 1`1 ce j -e -tom \1 b g Sv4 a C -i:eO‹
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 3—1 1 1. Building Permit Fee: $ Indicate how fee is etermined:
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 F�0;S`I !.�j
Check N �( heck Amount: uV Cash Amount:
6.Total Project Cost: $ 5 ?)1 1 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 informati•n
contain ' this application is true and accurate to the best of my knowledge and understanding.
nt wn ' uthorized 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 unregistere• contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbi•ation
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program c. I be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.go /dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks .' 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"
Permit Authorization
mass save Form
Site ID: 4527427 Customer: TERESA KELLOGG
Teresa Kellogg , owner of the property located at:
(Owner's Name,printed)
32 FAIRWAY DR NORTHAMPTON, MA 0106
(Property Street Address) (City)
herb authorize the Mass Save Home EnergyServices Program assigned Participating Contractor listed
hereby g g P g
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature: TO 2 Kepi
Date: 07 / 13 / 2022
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 F:r C.Iffi:e Use Cnl°y
�AM�
i�o City of Northampton
ti SAS SICK
r I Massachusetts ,
�" ;' DEPARTMENT OF BUILDING INSPECTIONS �
212 Main Street • Municipal Building tif�b � �
Northampton, MA 01060 n
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: ?2 Ru cbC
Contractor
Name: ffel1 Col ar , L(-- C
Address: N{kJ.)-TO S+
City, State: �c' C1/44 o tea
Phone: 13 - s3a R(1
Property Owner
Name: Ie.`-CSC& \ el ( G5c)
Address: 3vZ T rwQi
City, State: NO r1
1, Qo (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 -7 l (6 ( Z 2
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
` = 600 Washington Street
Boston,MA 02111
-• w x '" 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 (5 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. El 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 12.0 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 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: 3 a r1 Dr City/State/Zip: 11)(5 ha'-v a
Attach a copy of the workers' compensation policy declaration page(showing-the-policy-number—and expi tion date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal p nalties 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 O ER 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 Of ce 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#: