17C-128 (6) i
A&
BEYOND'' GREEN
CONSTRUCTION
DEBRIS DISPOSAL AFFIDAVIT
IN ACCORDANCE WITH THE COMMONWEALTH OF
MASSACHUSETTS DEBRIS DISPOSAL PROVISIONS OF
MASSACHUSETTS GENERAL "W CHAPTER 40, SECTION
54, 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*
55 N Maple Street Florence, MA,01062
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 12/30/15
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:
Address of Work: 55 N Maple Street Florence, MA 01062
Owners Name: Lisa Melnick
Date of Permit I Application: 12/30/15
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: 12/30/15 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.#
Massachusetts-Department of Public Safety
Board of Building RegOlations and Standards
Construction 5upejrcior
License:CS-07t539
l ��
SEAN R JEFFORI�
13 TERRACE VIM V s
EASTHAMPTOPf IYIA
A"" Expiration
Commissioner 11/28/2016
r
- Office of Consumer Affairs end Business Regulation
10 Park Plaza -!Suite 5170
Boston, Massach�setts 02116
Home Improvement Contractor Registration
Registration: 131279
Type: Individual
Expiration: 6/29/2016 Tr# 254174
SEAN JEFFORDS
SEAN JEFFORDS " ----- -
13 TERRACE VIEW - ----------------___ __--
EASTHAMPTON, MA 01027 -- - - - --- ---
Update Address and return card.Mark reason for change.
E Address ',`_ Renewal Employment –j Lost Card
SCA 1 CO 20M-05111
_ I
/h�rer�Affaircu&Bu off g a do P/Li Licens or registration valid for individul use only
Office of Consumer Affairs&Busi6ess Regulation � g Y
OME IMPROVEMENT CONTRACTOR before�he expiration date. If found return to:
l egistration: 131279 Type: Office 4f Consumer Affairs and Business Regulation
xpiration: 6/29/2016 Individual 10 Par Plaza-Suite 5170
Boston,jMA 02116
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW g -
EASTHAMPTON,MA 01027 �' --____i ---------__ ___—______—
Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
ti www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): 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. 1 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. New construction
2.❑ 1 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 for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 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 WEATHERIZATION
employees. [No workers' 13.0 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:APRIL 21, a
Job Site Address: 55 N Maple 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 a
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 ju t the information provided above is true and correct.
Signature: Date: 12/30/15
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#•
The Commonwealth of Massachusetts
�L 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:
I
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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 I 'formation: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Cheek if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPtRTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Buil ing Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total'Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Othei Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $
Check Nc. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paidvgi Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
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
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
_ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
-71(5
-Pfmt Owner's N c gnature) 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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. ov/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 halFbaths
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"
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-074539 x1MM 11/28/2016
SEAN R JEFFORDS
j License Number Expiration Date
Name of CSL Holder t 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 Burning Appliances I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 131279 6/29/2016
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 413-529-1544 Email address
Easthampton,MA 01027
City/Town,State,ZIP Telq hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.f 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..........CY,X Nb...........❑
SECTION 7a:OWNER AUTHO TION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT R 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 autho i ed by this building permit application.
SEE ATTACHED SIGNATURE AUTHORIZATION FORM 12/30/15
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUT ORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the p"and penalties of perjury that all of the information
contained in this application is true and accurate to the of owledge and understanding.
SEAN R JEFFORDS 12/30/15
Print Owner's or Authorized Agent's Name(Electronic Signa Date
N S:
1. An Owner who obtains a building permit to do his/her,own work,or an owner who hires an unregistered contractor
(not rcgistercd in the Home Improvement Contractor HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c.142A.Oth�r important information on the HIC Program can be found at
www,mass.gov/oca Information on the Construction upervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the info ion below:
Total floor area(sq.ft.) 0 luding 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 j Enclosed Open
3. "Total Project Square Footage"may be substituted fotj"Total Project Cost"
/o)-)
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts State Building Code,780 CMR
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
Ll Property Address: 1.2 Assessors Map&Parcel Numbers
5 N Maple Street Florence, MA 01062
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 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:
Lisa Melnick Florence, MA 01062
__ _
Name(Print) City,State,ZIP
55 N Maple Street 413-961-9018
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(,) ❑ 1 Alteration(,) ❑ 1 Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units I Other [2K Specify:Weatherization
Brief Description of Proposed Work2:IMPROVE ATTIr INSI11 ATION TO 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 $ 11 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 $ Total All Fees:$ (p
Suppression)
I Check N Check Amoun: Cash Amount:
6.Total Project Cost: $ C)CO ❑paid in Full' ❑Outstan ing Balance Due:
File#BP-2016-0862
APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 Q
PROPERTY LOCATION 55 NORTH MAPLE ST
MAP 17C PARCEL 128 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid o
Building 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:
Approved 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
Demolitio elay
ure Building drfficial 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.
55 NORTH MAPLE ST BP-2016-0862
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 128 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-2016-0862
Project# JS-2016-001453
Est Cost: $1000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sy. ft.): 11238.48 Owner: MELNICK LISA
Zoning: URB(100)/ Applicant: BEYOND GREEN CONSTRUCTION
AT. 55 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON:11512016 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 Signature:
FeeType: Date Paid: Amount:
Building 1/5/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner