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15B-030 (3) BP-2023-0108 246 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-030-001 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-2023-0108 PERMISSION IS HEREBY GRAN D TO: Project# INSULATION 2023 Contractor: License: Est.Cost: 7440 GREEN COLLAR LLC 108817 Const.Class: Exp.Date: 08/31/2024 Use Group: Owner: DAILY, SUSAN &BROWN, MICH L Lot Size(sq.ft.) Zoning: RR Applicant: GREEN COLLAR LLC Applicant Address Phone: Insurance: 570NEWTON ST (413)532-1817 R2WCI182010 SOUTH HADLEY, MA 01075 ISSUED ON: 01/31/2023 TO PERFORM THE FOLLOWING WORK: INSULATI ON/WEATHERIZATI 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: 1113*-s • it Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner A4 A 5 ii' � icr Ig7y The Commonwealth of Ma achu.etts✓ �' = Board of Building Regulation and andari a? / FOR 0 ICIPALITY Massachusetts State Building ode.,:. CMR �� / U Building Permit Application To Construct,Repair, • _ * I emolish Revised Mar 2011 One-or Two-Family Dwelling TON 'spFeT This SectionFor Official Use Only - --. Ns Buildin 'Permit Number: 3,/0f Date Applied: 1<' w 3/ -.s ,e 1• 31'70Z5 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addreegs: 1.2 Assessors Map&Parcel Numbers Q[ -I Lo Coe` r i'i d 'RCS . 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❑ Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal sys'.em 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.L Owner'of Record.;„ V5coL )r, 1.\60-hc�.v #Dc . rC . Name(Print) City,State,ZIP /NU Cr PAd Rd . aaic- s-n -1IA ty,ic:ko' br0 anal[ . rom No.and Street Telephone Eail Address-3 SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Oil Specify:Insulation/Weath-rization Brief Description of Proposed Work2: Insulation/Weatherization Tn l-o\I knee Waal s\ c, - 3" ibex c(as bo.M►r , C F4A ins ail kr-te L► col,1 S\e�t. - 2t" finer rcc2x o\ c sp -1 S 3) SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1 y�0. O'O 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 F es:$ ov Check No6� Check Amount: Cash Amount: 6.Total Project Cost: $ —1,yy D 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 8/23/2024 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 Nanie 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 110 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 1 a3 Print Owner's Name(Electronic Signature) t6112a D to 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' 1' a p>'cation' true and accurate to the best of my knowledge and understanding. k alp Print wner's or Authorize ent's Name(Electronic Signature) ate NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered ontractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitrati in program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can b• found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/s•s 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or p a rch) 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" DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: Republic Services Name of Waste Facility 845 Burnett Rd, Chicopee MA Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L. c. 40 s. 54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. I I s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department. If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official, in writing,as to the location where the debris will be disposed. 780 CMR—6th Edition Robert Calhoun Signature of Permit Applicant 1 k \ 3 Date The Commonwealth of Massachusetts mm_ Department of Industrial Accidents ._,i: Office of Investigations 600 Washington Street e p}; Boston, MA 02111 k maw �I'W" 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 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. n Remodeling 2.n I am a sole proprietor or partner- 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.I required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbingrepairs or additions 3.E I am a homeowner doing all work 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: ,Q 1 AU C hesVex- t-1-C Ci c d • City/State/Zip:N(X-k�1(,.M p 'n • rn Q • 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: k aLe ( a.3 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#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building RReq I lations and Standards Constrti tort SiOttvisor 11 y CS-108817r a E�kpires:08/23/2024 ROBERT C 41, /r�r� 8 UPPER R RO ' SOUTH HADL Y MA r. i4y ti „.„1.1' Com?ssidrlcr " s-` I c. .///' %i/'//////('////'/'1//?/ (//. /(////'///////-)WA% Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 181415 GREEN COLLAR LLC. Expiration: 03/31/2023 570 NEWTON ST SOUTH HADLEY,MA 01075 Update Address and Return Card. SCA 1 0 20M-05,- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Exoiratiofl Office of Consumer Affairs and Business Regulation 181415 03/31/2023 1000 Washington Street -Suite 710 GREEN COLLAR LLC. Boston,MA 02118 STD,EN ECKMAN 570 NEWTON ST 0",,e/ 2 SOUTH HADLEY,MA 01075 Not valid without signature Undersecretary Permit Authorization mass save Form Site ID: 4700538 Customer: MICHAEL BROWN Michael Brown ,owner of the property located at: (Owner's Name,printed) 246 Chesterfield Rd Northampton, MA 01053 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractpr listed below to act on my behalf and obtain a building permit to perform insulation and/or weatheriz tion work on my property. Owner's Signature: Mact$rTI Date: 01 / 11 / 2023 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 For Office Use Only