23D-029 (4) B -2023-0107
460 ELM ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23D-029-001 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-2023-0107 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 5567 GREEN COLLAR LLC 108817
Const.Class: Exp.Date: 08/31/2024
Use Group: Owner: LEOPOLD REBECCA A
Lot Size (sq.ft.)
Zoning: URB Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON: 02/01/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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 VI li LATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I >2 . �
i
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
! `� �_
5 3 / � l0 5
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The Commonwealth of Massachuses. ��
W Board of Building Regulations and Sta f CIP
ALITY
yn FOR
MUNICIPALITY
Massachusetts State Building Code,780 C` Il , >,,�s� USE
Building Permit Application To Construct,Repair,Renovate Orr pd a Revised Mar 2011
0
One-or Two-Family Dwelling
,/� This,.Section For Official Use Only,
Building P it Number: 6f� ?' iv 7 Date Applied: 10.4✓-1
tan,.-1 /, ems /C Z-l-ZLZ3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address:�I 1.2 Assessors Map& Parcel Numbed
IA 40 rn ��
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: 1
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 CIPrivate 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Reco d:
Ke,iC C fi .Co pc)( d. Wckkr)oum i(r a •
Name(Print) City,State,ZIP
Lk ISO E\m Sk • yt3- lo5F%-5$15
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) I
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 al Specify:Insulation/Weatherization
Brief Desclption of Propos Work2: Insulation/Weatherization
Ln-ylcr X1 �- o LA.nre.&cr is -c.d. - Se.-4 le.d c.e`I la kosr_br
.ccbuiv21� A- cn cL -cc - (josa\ .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 5,5 toi . ski, 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fe
Suppression)
Check Nt Check Amount: Cash Amount:
6.Total Project Cost: $ '3,5 1.0- 8� ❑Paid in ull 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 3/3l/20 3
Green Collar,LLC HIC Registration Number Expiration Date
HIC Comnanv 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 MI 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 i a(o I a3
Print Owner's Name(Electronic Signature) ate
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 ' ation is true and accurate to the best of my knowledge and understanding.
Print wner's or Au prized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who ob ins 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/dos
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"
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Rei Cations and Standards
Constion Srvisor
CS-108817 Y E pires:08/23/2024
ROBERT C ,g
8 UPPER R RRD am
SOUTH HADCFY MA 181
7i%
Con:miss:6 =r ;a,. I
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-051-
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 Expiration Office of Consumer Affairs and Business Regulation
181415 03/31/2023 1000 Washington Street -Suite 710
GREEN COLLAR LLC. Boston,MA 02118
STEVEN ECKMAN
570 NEWTON ST
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
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(re i uired):
1.® I am a employer with 15 4. ❑ I am a general contractor and I 6. New construe ion
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. ❑ Building addi ion
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical rep irs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing rep:irs 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' 13.1X1 OtherInsulati n/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 i i dicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those ntities 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: 'girl Ek i • City/State/Zip: WOc-E-hOSO kOn • fl—
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: 10 to a 3
Phone#: 413 532 1817
Official use only. Do not write in this area, to he 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. Plumbin Inspector
6. Other
Contact Person: Phone#:
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. III 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
t �aQ 3
Date
City of Northampton
jMassachusetts �� ` `�
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building �'� � ‘1.
�e
Northampton, MA 01060 :::46
Property Address: 460 Elm St
Contractor Green Collar, Ilc
Name:
Address: 570 Newton ST
City, State: South Hadley, Ma
413-532-1817
Phone:
Property Owner
Name: Rebecca Leopold
Address: 460 Elm St
City, State: Northampton, Ma
I Green Collar,LLC (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 9?o-6ent C'aMRoun
Date 2/1/23
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing n
Or Doors E
Accessory Bldg. ElDemolition IIINew Signs (p] Decks [Q Siding[p] Other[p]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction, Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 1 6 0 6 cc iq L e O 1'L, j'i? , as Owner of the subject
property
hereby authorize
to actin q,y behalf, in all matters relative to work authorized by this building permit application.
<� / /�- � ��-/ // — i6 ..c2 2 .
Signature of Owner Date
I, (;•--Oce.c.4 L1.=6 14, 4. r
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
0 ln L'2<A- L-k Pcc, 12
Print Name
Signature o Owner/Agee Date
r