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16C-003 (3) a y m PERMIT AUTHORIZATION FORM 1, Jonathan Langmuir ,owner of the property located at: (Owner's Name,printed) 334 Spring St. Florence (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X Owner' re f Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date D�rO For Office Use Only Rev.12132011 AgF\ BEYOND GREEN CONSTRUCTION DEBRIS DISPOSAL AFFIDAVIT IN ACCORDANCE WITH THE COMMONWEALTH OF MASSACHUSETTS DEBRIS DISPOSAL PROVISIONS OF MASSACHUSETTS GENERAL LAW CHAPTER 40, SECTION 541 A CONDITION OF BUILDING PERMIT NUMBER FOR DEMOLITION WORK IS THAT THE DEBRIS RESULTING FROM THIS WORK SHALL BE REMOVED FROM SITE AND DISPOSED OF IN A PROPERLY LICENSED SOLID WASTE DISPOSAL FACILITY AS DEFINED BY MGL C111, S 150A. FACILITY- ALTERNATIVE RECYCLING, NORTHAMPTON, MA CONSTRUCTION SITE ADDRESS- 334 SPRING ST.,FLORENCE,MA 01062 TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTION or ALTERNATIVE RECYCLING SIGNATURE DATE 2/12/2014 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application Suggested Affidavit For Home Improvement Contractor Permit Application For Office Use Only Permit No.: Date: Note 142 A, requires that the Areconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal or demolition or the constructional of an addition to any pre-existing owner occupied building containing at least one but no more than four dwelling unit,or to structures which are adjacent to such residence or building@ be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: WEATHERIZATION-INSULATION Est. Cost: $3,002.00 Address of Work: 334 SPRING ST.,FLORENCE,MA 01062 Owners Name: JONATHAN LANGMUIR Date of Permit/Application: 2/12/2014 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$ 500.00 Building not owner occupied Owner pulling own permit Other(specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142A. Signed under penalties of perjury: �,- I hereby apply for a permit as the agent of the owner: Date: 2/12/2014 Contractor: BEYOND GREEN CONSTRUCTION Reg. # : 131279 OR: SEAN R JEFFORDS Not withstanding the above notice, I hereby apply for a permit as the owner of the property. Date: Owner: Tel. # : Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen icor License CS-074539 SEAN R JEFFOW 13 TERRACE VIEW EASTHAMPTON MA 0 ` Expiration Commissioner 11128=14 � �jie �a�►�.n�tr�eal,� �.i��ataf�� Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration RepWaatim: 131279 Two: bfiiMi" FS Ofh 629014 TA 223916 SEAN JEFFORDS SEAN JEFFORDS 13 TERRACE VIEW EASTHAMPTON, MA 01027 Update Addrwa sad *W cane.Kwt rea ws fw champ - 0108-W 8 soW440�410121e - Q Addrais ❑ Raw" ❑ Enpleyae t ❑ L"card Licene or tieooba0aa rsiid for iadhi"me aully °`� OfRee etCsawwsr Atbiis!ttiises��� HOME 0W`R0VE1WW CONTRAC'M before the expkadw dabs. U!laud Man to. Raykllra" 131279 Type: Ofee of Caaaawr A®ain sad Bsaisieas Russ W4 incniirm al 10 Park Pbtsa-Sane 6170 E'�'I'atl0 i Berton,MA 02116 SEAN JEFFORDS SEAN JEFFORDS. - 13 TERRACE VIEW.. EASTHA&V TON.MA S*W Not Vaud wBtaat sipstam r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let?ibly Name(Business/OrganizatiorOndividuat): Beyond Green Construction / Sean R Jeffords Address: 13 Terrace View City/State/Zip. Easthampton, MA 01027 Phone#:413-529-0544 Are you an employer?Check the appropriate box: Type of project(required): 1.[X I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time)." have hired the sub-contractors 6. F]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 g, ❑Demolition working or me in an capacity. employees and have workers' g Y P h'• t 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. Roof repairs insurance required.]t a 152,§1(4),and we have no employees. [No workers' 13.[XOther Weatheri ate lop 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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 Co. Policy#or Self-ins.Lic.#: SEWC469389 Expiration Date: 4/21/2014 Job Site Address: 3 3 4 5 p r n 9 S"I) Flo r"G¢-) �4 0. City/State/Zip: O 1 O fo 2 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: 2/12/2014 Phone#: 413-529-0544 Official use only. Do not write in this area,to be completed by city or town oJj'iciaL City or Town: Permit/License# Issuing Authority: Building Department Contact Person: Phone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-074539 11/28/2014 SEAN R JEFFORDS License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 13 TERRACE VIEW --- No.and Street Type Description EASTHAMPTON, MA 01027 U Unrestricted(Buildings to 35,000 cu.ft. R Restricted 1&2 Family Dwelling CitylTown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 413-529-0544 sean @beyondgreen.biz SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 131279 6/29/2014 Sean R Jeffords-Beyond Green Construction HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 13 Terrace View _ sean @beyondgreen.biz No.and Street Email address Easthampton, MA 01027 413-529-0544 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..........q(X 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 BEYOND GREEN CONSTRUCTION to act on my behalf,in all matters relative to work authorized by this building permit application. SEE ATTACHED SIGNED PERMIT AUTHORIZATION 2/12/2014 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW 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 ac of my knowledge and understanding. cure SEAN R JEFFORDS 2/12/2014 Print Owner's or Authorized Agent's Name(Electrons ignature) 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.massgov/oca Information on the Construction Supervisor License can be found at www.mass.go`gs 1 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'maybe substituted for"Total Project Cost" FEB 14 2014 ctrl of Massachusetts uilding Regulations and Standards FOR Massachusetts State Building Code,780 CMR MUNIUSE L1TY Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Nam Signature Date CTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 334 SPRING ST. LORENCE, A01062 Lla Is this an accepted Ave 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes13 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners of Record: JONATHAN LANGMUIR FLORENCE,MA01062 _ Name(Print) City,State,ZIP 334 SPRING STREET 413-237-7326 7blangmuirll8 @yahoo.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction+E03Accessory isting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition Bldg.❑ Number of Units Other CSC Specify:Weatherization Brief Description of Proposed Work : AIR SEALIG MEASURES. ATTIC FLOOR OPEN BLOW-- CELLULOSE 8". BASEMENT RIM-7.0IST INSULATE 2" POI YISO__ _.._.. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:S-5 j o0lndicate how fee is determined: 2.Electrical $ 19 Standard City/Town Application Fee ❑Total Project Cose(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $_ 4.Mechanical (HVAC) $ List: _ 5.Mechanical (Fire $ Total All $ S S_Q n Suppression) Check Check Amount: Cash Amount: 6.Total Project Cost: $ 3,002.00 ❑Paid in Full ❑Outstanding Balance Due: File#BP-2014-0872 APPLICANT/CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416)529-0544 PROPERTY LOCATION 334 SPRING ST MAP 16C PARCEL 003 001 ZONE URA000)/WSP(100V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC&BASEMENT RIM INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 074539 3 sets of Plans/Plot Plan THE FOLLOWjNG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORM N PRESENTED: Awfoved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management emo y Sight1fiffe of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 334 SPRING ST BP-2014-0872 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16C-003 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-0872 Project# JS-2014-001525 Est.Cost: $3002.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 43864.92 Owner: LANGMUIR JONATHAN Zoning:URA(100)/WSP(100)/ Applicant: SEAN JEFFORDS AT. 334 SPRING ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (416) 529-0544 WC EASTHAMPTONMA01027 ISSUED ON:211412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & BASEMENT RIM INSULATION 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 2/14/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner