37-093 (6) BP-2023-1020
19 ICE POND DR COMMONWEALTH OF M • SSACHUSETTS
Map:Block:Lot:
37-093-001 CITY OF NORTH • I PTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGLTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUA' • TY FUND (MGL c.142A)
BUILDING PI RMIT
Permit# BP-2023-1020 PERMISSIO IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 4389 GREEN COLLAR L I C 108817
Const.Class: Exp.Date: 08/31/20.4
Use Group: Owner: SUSANNAH HOWE NICHOLAS R &
Lot Size (sq.ft.)
Zoning: SR Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON: 08/01/2023
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: I 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 NOITHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
• ♦' j2 '1 •
1 I , _
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
t/ V/' iLj 2069
The Commonwealth of Massachus r v
.0)' Board of Building Regulations and Stan R
Massachusetts State Building Code,780 �4pM t USE LITY
c
Building Permit Application To Construct,Repair,Reno ate O% ish a evised r 2011
One-or Two-Family Dwelling 9a,
/J This Section For Official Use 0 ly
Building Permit Number: y-4 �f /00 Date Applied:
l(. '
u i rJ i,/Z ,
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
\O 1cC 'findL--0-' .
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 0 Private El Municipal_ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
k)i GY`o\.c li Q 1 )o r rnrk rniaturl , iv(,(. (-U A ()Co )—
Name(Print) City,State,ZIP
1`1 IC POr\c1 7.3r (LO3) - 8'f)-3R
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 5] Specify:Insulation/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
InS-t A 3" C \\ <. --tom I ,D 3u s i 5-a- •
1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) I Official Use Only
1.Building $ 1. Building Permit Foie: $ Indicate how fee is determined:
" l ❑Standard City/Tovin Application Fee
2.Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fee
U Check No�j 16 Check Amount:(J Cash Amount:
6.Total Project Cost: $ 13 Ill 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Boa ss
Massachusetts a°j
4t vim..
DEPARTMENT OF BUILDING INSPECTIONS yJ °'
212 Main Street • Municipal Building °fs� 3'7�1JC
Northampton, MA 01060 _
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address:
Contractor
Name: Green Collar,LLC
Address: 570 Newton ST
City, State: South Hadley, Ma
Phone: 413-532-1817
Property Owner
Name: `c hC O- OLUQ
Address: \CA \ P ?GnCl
City, State: N)rkhC\mrv-oc )
Robert Calhoun
(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 :ila&ent eaLhowi
Date —1 " I ` �. �
City of Northampton
� SAC�•� "'r Massachusetts �? �-- '�
rIG.
,t ' ( - ' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building J61.
�C�
\• L✓ Northampton, MA 01060 sMjy TO%1
Debris 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.
The debris from construction work being performed at:
���
(Please print house number and street name)
Is to be disposed of at:
-k0 .0
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Republic Services 845 Burnette Rd, Chicopee MA
(Company Name and Address)
J`ta&ext CaP oun,
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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 3/31/2025
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 name below,I hereby attest under the pains and penalties cif perjury that all of the information
contained in this tion is true and accurate to the best of my knowledge and understanding.
Print er's or A rizell Ancnt'c 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.) Habita)le 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 Massa husetts
•
Department of Industrial Ac idents
Office of Investigation
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.® 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. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
p �' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
requir
ed.]u 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.❑ 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' 13.0 Otheiinsulation/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: 1°1 0 C O r1 City/State/Zip:�CX-
*\0.1M "C.�? IYl CL
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 perjmy 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 to n official.
City or Town: Permit/Licen e#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.E ctrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Commonwealth or Massachusetts
® Division of Occupational Licensure
Board of Budding Regulations and Stindar4s
C �^a
')fl, . tottSl1
t4astir
CS-108817 expires.08/23/2024
ROBERT CAtf1OUN
8 UPPER RIVER RD
SOUTH HADITY MA 01075
x.
dr)/il,1 I
r,o
vuunwaw nl.,
THE COMMONWEALTH OF MASSACHUSETTS
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: 03/31/2025
570 NEWTON ST
SOUTH HADLEY,MA 01075
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:LLC Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
181415 03/31/2025 Boston,MA 02118
GREEN COLLAR LLC.
ROBERT CALHOUN ,) glittleXt
570 NEWTON ST ✓(/i140s4'
SOUTH HADLEY,MA 01075
Undersecretary Not valid without signature
GREE
COLLA
Permit Authorization Form
I Nicholas Howe
(Owner's Name)
Owner of the property located at:
19 Ice Pond Dr
(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.
(Owner's Signature)
7/19/2023
(Date)
351 Newton St. Unit B South Hadley, MA 01075 Phone:413.532. 1817 Email: support@greencollarma.com