12C-056 (10) BP-2023-0036
16 HAROLD ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12C-056-001 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-2023-0036 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 2352 GREEN COLLAR LLC 108817
Const.Class: Exp.Date: 08/31/2024
Use Group: Owner: KAC ZORN MARTHA W&NICHOLAS J
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 R2WCI182010
SOUTH HADLEY, MA 01075
ISSUED ON: 01/12/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WE ATH ERI 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: I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECE �
v►�-r 19'18 J A N 1 ? 21123
The Commonwealth'of Massachusetts'
Board of Building Regal ions and Standards FOR
MUNICIPALITY
Massachusetts State BuildinQFftti q(804, o:�s USE
THAMr rc)N MA 01060
z Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
- One-or Two-Family Dwelling
Q
This Section For Official Use Only
Building Permit Number: 64-A 3 3 6/ Date Applied:
ilex. 255 /74? i- )2-7--02Z
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Asses s Map&Parcel Number
Ito �urotu.St I'
1.1a Is this an accepted street?yes no Map Number Parcel Numb
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 Pro ded
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System
Public CI Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal sy tem 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
.41C, 0tac i(o s I-(0)-ence , hnc`
Name(Print) City,State,ZIP
Oifirold S+ 4-113-576' SYGg
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:Insulat on/Weatherization
Brief Description of Proposed Work2: Insulation/Weatherization
I nS+a,u Ut cei,l u tie_ -to S1(4v Si Q►�ao� 0.0k41
�l c,
nSl- 1 t a' �Fi by S co Ol b 4f* o(arrrn-t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 2 ,35a 1. Building Permit Fee:$ Indicate how fee is c4etermined:
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 Fees:
_ Check No.0 �}Check Amount Cash Amount:
6.Total Project Cost: $
o(. 3 "'- 0 Paid in Full ❑Outstanding Balance Due:_,
A
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 35,00 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) 181 15 3/31/2023
Green Collar,LLC HIC Registration 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 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: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 in this application is true and accurate to the best of my knowledge and understanding.
ioeCa
Print Owner's or Authorized 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.govidps
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.) 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"
DocuSign Envelope ID:B62B1A33-DAAA-4162-A308-24EF780296AC
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
Nicholas Kachulis
(Owner's Name)
owner of the property located at:
16 Harold Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize r Cot r, �•�-
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
-DocuSigned by:
ti(CUAS 644ALS
Ow`'6Ftengintyre
12/1/2022 1 8:10 AM EST
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
The Commonwealth of Massachusetts
�
Department of Industrial Accidents
�E
,�.. Office of Investigations
600 Washington Street
Boston, MA 02111
*- _`��, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansAPlumbers
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. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. El Building addition
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.❑ Plumbing repairs or additions
[No workers
myself. ' right of exemption per MGL
Y comp. 12.❑ 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: 't klarkl S I- City/State/Zip: T1 orenj,Ma-
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:
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#:
City of Northampton
.jr
r Massachusetts x_ �e
c,
w w c
d DEPARTMENT OF BUILDING INSPECTIONS
+ 4.. 212 Main Street •Municipal Building Ja� Ca,
\AWL r +' Northampton, MA 01060 fkjy %'
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:
1 t-lawl
(Please print house number and street name)
Is to be disposed of at:
(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)
JZc8ent Calhoun
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.
--_ H�M, City of Northampton
,,
tos. y� ls`S S�r
k." Massachusetts o``' '`- '<<1 -_,A ik t t i
mow, 4 ° DEPARTMENT OF BUILDING INSPECTIONS tiJ a�
\ r 212 Main Street • Municipal Building tpS `�O
\\117 ' Northampton, MA 01060 �'h' 3')'
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 1 140J1 l Ct S 4-
Contractor
Name: Green Collar,LLC
Address: 570 Newton ST
City, State: South Hadley, Ma
Phone: 413-532-1817
Property Owner h
Name: V tC�(10 S KO�fr{'�(,e.�,l S
Address: 1 ( too r ct S
City, State: 1-' \Or Cfl Cie i rY1 CL-
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 .let eaMaun
Date
halt 1a-),_
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
Constcion S,rvisor
CS-108817 t spires:08/23/2024
ROBERT C
8 UPPER RR
SOUTH HADL' Y MA ell H/
`�
Comrnissidncr ;",' f
/� i/.
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
GREEN COLLAR LLC. Registration: 181415
570 NEWTON ST Expiration: 03/31/2023
SOUTH HADLEY,MA 01075
Update Address and Return Card.
SCA 1 0 20M-e51-
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
STB,EN ECKMAN
570 NEWTON ST %
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature