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16A-020-051 BP r 022-1381 406 FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16A-020-051 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-2022-1381 PERMISSION IS HEREBY GRANT, D TO: Project# INSULATION Contractor: License: Est. Cost: 3901 GREEN COLLAR LLC 108817 Const.Class: Exp.Date: 08/31/2024 Use Group: Owner: MELISSA HENDRICKSON 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: 10/26/2022 TO PERFORM THE FOLLOWING WORK: INSULATI ON/WEATHERI 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: V , .y2 . Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner v V �JV, ,'7S7 �cr 2 Th Commonwealth of Massachusetts S C oar of Building Regulations and Standards FOR MU�� as chusetts State Building Code,780 CMRNIom USE LITY T`Sui� it A plication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 °jOso0Ns One-or Two-Family Dwelling Q This Section For Official Use Only Building Permit Number: 84 A). ' 13Q I Date Applied: Z-v,a 745 / /0'25-2ozz Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property !p��D Address:r� v' 1.2 tsses�prs Map& Parcel Numlore: „ 1.1 a I'ss this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Usc 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 ❑ 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:. Mai s 1AC l-N.Ciy'cr scr Las ,YYIGI. Name(Print) City,State,ZIP Liu, fair U1 g Li►3 --)a.1 - 35-5�o 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 W Specify:Insulation/Weatherization Brief scription of Pro sed Work2: Insulation/Weatherization �o�Se_rrvat' .A. '-j0-- tber�la,S S -1-o �7'(1 �6-�a- -Up cab-kit a S t -°w ( 8 J 5V-4 — C_ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 3 r q 0 I 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: q Check No.63O heck Amount. Cash Amount: 6.Total Project Cost: $ 7J l n 1 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 108817 8/23/2024 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 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 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:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my • e below,I hereby attest under the pains and penalties of perjury that all of the information contained in .lication is true and accurate to the best of my knowledge and understanding. Print Owner's I ••;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,fmished 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" SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name oI CSI.!!older List CSL Type(see below)— . _......No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.fi.) It Restricted l&2 Family Dwelling Cityr Town,State.ZIP i\i Marrnnr RC Rooting Covering —._ WS Window and Sidipg SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address I) Demolition 5.2 Registered Home improvement Contractor(HIC) IIIC Registration Number Expiration Date I I1('Company Name or IIIC Registrant Name No.and Street Email address 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 0 No 0 SECTION 7a: OWNER AUTHORIZATION TO 13E COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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.. /el/ V . Print Owner's Name(Electronic Signature) Date Y7/ z SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 13y entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this a cation is true and accurate to the best of my knowledge and understanding. ,_ . . 3/7 /A?... Print Owner's or utharh'ed Agent's Name(Electronic Signature) Date NOTES: I. 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 I IiC Program can be found at www.mass.sov/oca information on the Construction Supervisor License can be found at www.mass.govfdps 2. When substantial work is plumed,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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations µ:me 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.E 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. n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P Y 9. n Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. n We arc a corporation and its 10.0 Electrical repairs or additions 3.17 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.n 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 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: 9/23/2023 Job Site Address: 4Od C G��Gam [0) . City/State/Zip: S 'MX' Attach a copy of the workers' compen tion 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#: