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17A-248 (7) OWNER AUTHORIZATION FORM (Owners Name) owner of the property located at (Property Address) V6 ce-, c t b6 (Property Address) hereby authorize 0 (Su n ctor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Sign + ;C) Date t 1t � i� 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- 98 Lake Street, Florence, MA, 01062 TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTION or ALTERNATIVE RECYCLING SIGNATURE DATE 5/13/15 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 Est. Cost: 1,000.00 Address of Work: 98 Lake Street, Florence, MA, 01062 Owners Name: Maren Brown Date of Permit/Application: 5/13/15 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: 5113/15 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. # : The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Apyflcant Information Please Print LeLibly Name(Business/Organization/lndividual): BEYOND GREEN CONSTRUCTION / SEAN 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.© I am a employer with 3 4. 0 1 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. E]Demolition working or me in an capacity. employees and have workers' g Y P tY• $ 9. n Building addition [No workers' comp.insurance comp. insurance. required.] 5. We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I Ln 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 WEATHERIZATION employees. [No workers' 13.■E Other 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:NorGUARD INSURANCE COMPANY � Policy#or Self-ins. Lic.#:SEWC585439 Expiration Date.Ay tr D- , ?'01 Job Site Address: 98 Lake Street City/State/Zip: Florence, MA, 01062 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 pe s of perjury that the information provided above is true and correct Signature: Date: 5/13/15 Phone#: 413-5290544 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#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-074539 XTgQNXN 11/28/2016 SEAN R JEFFORDS License Number Expiration Date Name of CSL Holder U 13 TERRACE VIEW List CSL Type(see below) No.and Street Type Description EASTHAMPTON, MA 01027 U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 413-529-0544 sean @beyondgreen.biz SF Solid Fuel Bruning Appliances 1 insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 131279 6/29/2016 6 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, Failm to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes..........4(X No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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 SIGNATURE AUTHORIZATION FORM 5/13/15 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 accurate 2z�knowled ge and understanding. SEAN R JEFFORDS 5/13/15 Print Owner's or Authorized Agent's Name(Electronic Sign 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(11IC)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-zov/0s /dos 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/badts 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" 7�",7",,,, MAY 262 015 Electric, HL;r loin, Inspections The Cornrnon tts ^'oso 1 Board of Building Regulations and Standards FOR Massachusetts State Building Code,780 CMR MUNICIPALITY USE 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 Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 8 Lake Street, Florence, MA, 01062 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Maren Brown Florence, MA, 01062 Name(Print) City,State,ZIP 98 Lake Street 413-586-0901 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repaim(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition Efl Accessory Bldg.❑ Number of Units I Other EX Specify:Weatherization Brief Description of Proposed Workz: IMPROVE ATTIC INSI11 ATION 10 CODE AND AIR SEALING MEASURES SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ Standard City/Town Application Fee ❑Total Project CosO(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check Na/00 Check Amount: Cash Amount: 6.Total Project Cost: $ 1,000.00 ❑Paid in Full ❑Outstanding Balance Due: File#BP-2015-1180 APPLICANT/CONTACT PERSON BEYOND GREEN ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544() PROPERTY LOCATION 98 LAKE ST MAP 17A PARCEL 248 001 ZONE URB(100)/ 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 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: proved 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 MoDelay yir V � 4i✓ Signature of uilding 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. 98 LAKE ST BP-2015-1180 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-248 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1180 Project# JS-2015-002209 Est. Cost: $1000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BEYOND GREEN 074539 Lot Size(sq. ft.): 16552.80 Owner: BROWN MAREN T&PATRICIA ANN MORRISON Zoning:_URB(100)/ Applicant: BEYOND GREEN AT. 98 LAKE ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (413) 529-0544 O WC EASTHAMPTONMA01027 ISSUED ON.512812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 Sienature: FeeType• Date Paid: Amount: Building 5/28/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner