29-201 (4) BP-2024-0059
55 OVERLOOK DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-201-001 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-2024-0059 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2024 Contractor: License:
Est.Cost: 4221 GREEN COLLAR LLC 108817
Const.Class: Exp.Date:08/31/2024
TONY D ROSA&ELSON ROSA&FLORENCE E
Use Group: Owner: ROSA
Lot Size(sq.ft.)
Zoning: WSP Applicant: GREEN COLLAR LLC
Applicant Address Phone: Insurance:
570 NEWTON ST (413)532-1817 WMZ-800-8008323
SOUTH HADLEY,MA 01075
ISSUED ON: 01/24/2024
TO PERFORM THE FOLLOWING WORK:
INSULATION/W EATHERIZATION
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: p' &r 2
6
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
, ----J_14,-,,;-----41a- )q69
SS, The Commonwealth of Massachu tts _;
Board of Building Regulations and S nda s `/AN 19 FOW'
Massachusetts State Building Code,/80 cS ��(C ICIPALITY
USE
Building Permit Application To Construct,Repair,Renova'te4 D a R ised/vfar 2011
One-or Two-Family Dwelling ' - �''_"'n,'Ai-•• Fcr - ft
I/, This S tion For Official Use Only �h. �? NS i
Building Pe it Number: 81,')v� - Date Applied:
cyi;1 1 - 23- z
Building Official(Print Name) Signature Datc
SECTION 1:SITE INFORMATION
1.1 Pro erg Address: 1.2 Assessors Map&Parcel Numbers
per-l00YL QC • 2/'-20 r- 00 1
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Gt)S P ,38 at4-c_,
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 t Private 0 Zone: _ Outside Flood Zone? Municipal On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor t O�Of^
Flore c crper .p WOc
Name(Print) City, taatt�e,ZIP
55 Ovex tr .Dr . yl�..? 2J l(81-4G
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) ❑ Addition ❑
Demolition 0 Accessory Bldg.0 Number of Units Other MI Specify:Insulation/Weatherization
bc..
Descri tioposed Work2
Ct11u10ce - B(olI• Sq-4.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Lila& 1 I. 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 Fee, s:,�(, 16, -
Check No i-�='I Check Amount: Cash Amount:
6.Total Project Cost: $ / i a 99 I CI 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 3/31/2025
Green Collar,LLC HIC Registration Number Expiration Date
HIC Comnanv Name or HIC Registrant Name
570 Newton St Support@greencollarma.com
No.and Street
South Hadley,MA 01075 413 532 1817 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 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: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 this application is true and accurate to the best of my knowledge and understanding.
_ laa
Print Owner's or Authorized Agent'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 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.) 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
.1 600 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):
LE I am a employer with 15 4. El 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
shipand have no employees These sub-contractors have
8. Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.
t
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 11.0 Plumbing repairs 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' I3.[XI 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: A.I.M Mutual Insurance Company
Policy#or Self-ins.Lic.#:WMZ-800-8008323-2023A(1) Expiration Date:_9/23/24 -^
Job Site Address: O lw k Dr . City/State/Zip: F/i ra)C'CI A-1
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjurj'that the information provided above is true and correct.
. /�cJSignature: Date:
Phone#: 413 532 1817
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Division ul Occupational Licensure
Board of Building Regulations and Standards
It
ConstL t t S to rvlsor
CS-108817 E9cpires:0812312024
ROBERT CAt`,11OUN
8 UPPER RIVER RD
SOUTH HADLTY MA 01076 % . Y�
Cornmr':,o :r
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
Registration: 181415
GREEN COLLAR LLC. Expiration: 03/31/2025
570 NEWTON ST
SOUTH HADLEY,MA 01075
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:LLC Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
181415 03/31/2025 Boston,MA 02118
GREEN COLLAR LLC.
ROBERT CALHOUN ' ,Wafteitt Ca un
570 NEWTON ST 'a,(6$
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [❑] Decks [[] Siding[DJ Other[DJ
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, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all mattefs,relative to work authorized by this building permit application.
Signature of ner 1-, Date Ct i � y 1.
I, , 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.
Hot' \: o \ :.
Print Name
.2
Signature of Owner/Agent Date ji L., l ( -e ,c,,(",t..(
GREEN
COLLAR
Permit Authorization Form
Florence Rosa
,
(Owner's Name)
Owner of the property located at:
55 Overlook Dr
(Property Address)
Florence, 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)
1/12/24
(Date)
351 Newton St. Unit B South Hadley,MA 01075 Phone:413.532. 1817 Email: support@greencollarma.com