17A-084 (3) 15 CAROLYN ST BP-2016-1398
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-084 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-2016-1398
Project# JS-2016-002410
Est. Cost: $3000.00
Fee: $78.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq. ft.): 13808.52 Owner: DAUBE JONATHAN
Zoning: R1(100)/URA(100)/WSP(93)// Applicant: BEYONDGREEN CONSTRUCTION
AT. 15 CAROLYN ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON.512512016 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 4 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 5/25/2016 0:00:00 $78.00
212 Main Street, Phone(4 1.3))587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2016-1398
APPLICANT/CONTACT PERSON BEYOND GREEN CONS RUCTION
ADDRESS/PHONE 13 TERRACE VIEW EAST14AMPTON01027(413)529-0544 O
PROPERTY LOCATION 15 CAROLYN ST
MAP 17A PARCEL 084 001 ZONE RI(100)/URA(100)/WSP(93)/
THIS SECTION FOR OFFICiIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT F
Fee Paid -
Building Permit Filled out
Fee Paid
T_ypeof 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolition Delay
7 L
Sig uil ing O' fficia1
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.
RECE�VEC�
Th Cot imonwealth of Massachusetts
1r' Board f B ilding Regulations and Standards FOR
Ulf P11
Massac ius s State Building Code, 780 CMR MUNICIPALITY
USE
aticn To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D'to Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 12 Assessors Map&Parcel Numbers
15 Caro ku In kQ C-Q Awit Gl t)
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 Y'rds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone In ormation: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco
J on
Name(Print) City,State,ZIP
5 C arcS�-
No.and Street IJ Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-OccWied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Tits Other 51 Specify:W(�ckk"e67-Cvt On
Brief Description of Proposed Work : f V t? nskklcutod-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Bui ding Permit Fee:$ '77 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ s
❑Tot Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$ '7 �
Check NoC? Check Amount: Cash Amount:
6.Total Project Cost: $ zC�� 0 paid;in Full 0 Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �c, 7
SEAN R JEFFORDS C� 01/"IJ8 9 I 0 lv
License Number Expiration Date'
Name of CSL Holder
List CSL Type(see below) L
13 TERRACE VIEW
Type Description
No.and Street U Unrestricted(Buildings up to 35,000 cu.ft.)
EASTHAMPTON,MA 01027 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413-529-0544 SEAN a@BEYONDGREEN.BIZ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 3
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
Cit /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 ..........X No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOUR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize , A00CJ
to act on my behalf, in all matters relative to work authorized y this building permit application.
bee cA-m( .h c/
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 acc to est of my knowledge and understanding.
_Sean Jeffords ,
Print Owner's or Authorized Agent's Name(Electrons 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.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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Indiistrial Accidents
Office of Investigations
600 Washington Street
Boston,M4 02111
www.mastgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaulicaut Information Please Print Legibly
Name(Business/Organization/Individual): , i K I i Pircm
Address: 13 R r r CA V
City/State/Zip: tM L'la 010 hone#: Ll I,3— 5 )1 - 0 5 y
Are you an employer?Check the appropriate box: Type of project(required):
1.ffI am a employer with —3 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired ft 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 g, ❑Demolition
working for me in any capacity. employees acid have workers' 9. ❑Building addition
[No workers'comp.insurance comp.insurahce.#
required.] 5. [] We are a cor oration 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 oxen ption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4) and we have no
employees. o workers' 13.('2]Other Z GL1 l
i comp.ins 4:0 required.]
*Any applicant that checks box#1 must also fill out the section below showing t it workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and n hire outside contractors must submit a now affidavit indicating such.
tContractors that check this box must attached an additional.sheat showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they roust provide their workers'comp.policy number.
zs�e�-fa -
I am an employer that is providing workers'compensation Insurance for my employees. Below is the pollcy and job site
Information.
Insurance Company Name: 00y' LkCkrC( r) S(t r CCP C 1C
Policy#or Self-ins.Lie.#: w EC 1 o Did Expiration Date:
Job Site Address: � �l�[ "S t ' City/State/Zip: t� CXnc G 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 MOL 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.
Ido hereby certify under the pains and penal'es of Jury tha#the information provided above Is true and correct.
Signature: a cJ' 00— 1 LO
P e#: _ �J a — o �(4
Official use only. Do not write in this area,to be completed city or town ofJlclal
City or Town: P rmit/License#
Issuing Authority(circle one):
2.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
1�! Massachusetts -Department of Public Safety
f Board of Building Reguiiations and Standards
Constructi'"11 )l'7 iuC
License: CS-074,09
SEAN R JEFFORI} ..
13 TERRACE VIIIW
EASTHAMPTONMA..
WO Expiration
Commissioner 11/28/2016
Office of Consumer Affairs a d Business Regulation
10 Park Plaza - uite 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.
Address Renewal ] Employment Lost Card
SCA?. w 20M-05111
� Office of Consumer Affairs&Busihess Regulation License',or registration valid for individul use only
g3 -- ME IMPROVEMENT CONTRACTOR
Obefore the expiration date. If found return to:
J 0 stration: 131279 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
1` xpiration: 6/2912016 Individual
Boston,MA 02116
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON,MA 01027 — — — —_—
Undersecretary Not valid without signature
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: ( 3�j
Address of Work: Jc� (�' ( 1�q 'Y-\ = of W C Q, NqC) C)(D �-
Owners Name:
Date of Permit 1 Application: - lG
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: 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. #
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 HALL 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-
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 5 a �
two
mass saveUM�R
savings thw.V+enaW tftemy
PERMIT AUTHORIZATION FORM
I, JONATHAN DAUBE ,owner of the property located at:
(Owner's Name,printed)
15 CAROLYN ST FLORENCE
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Progra assi ed Participating Contractor listed
below to act on my behalf and obtain a building permit to pe rm ins lation and/or weatherization
work on my property.
X
Owner's Signature
e �
r S
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
Di
For Office Use Only
Rev.12132011
City of Northampton
'f r•.. :. ` ,asks ...a!
�,. Massachusetts
DEPARTMENT OF BUIIGDING INSPECTIONS
!gyp 212 Main Street • Municipal Building 0R 4`a
Northampton„ MA 01060
Property Address: 1S Cir ala n STTL°r-t 4--Jorcrwe, t-kyi
Contractor
Name: RouarrA Arfcnn iT
Address: O
City, State: S` 'Ir'1 Gc n(�1Z V� t.�y� 010a]
Phone: aa- o5yu
Property Owner
Name: YlC'A�'{�1(�
Address:
City, State: --F (o Y /fit p O
I, 'Sean ) Y' (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
Date 5-ac)--t ca
BEYOND!
GREEN
C( € „� I ,
N
Dear Building Department,
Please send permit back to Beyond reen Construction by mail or via email
when it is issued. If you have any questionsl regarding this building permit please
call my cell @ 413-478-8631. See details b6low.
Address: Beyond Green Construction
13 Terrace View
Easthampton,MA,01027
Email Address: nicoleibeyondgreen.biz
Thank you!
cr/cole�?e ca-6
; I Project Coordinator
Cell:413.478.8631 Office:413.529.0544
13 Terrace View,Easthampton I www.beyondgreen.biz
i
i
Beyond Green Construction "Leaders in Energy Efficiency" Phone:413-529-0544
13 Terrace View Established 1998 www.BeyondGreen.biz
Easthampton, MA 01027 CSL#74539
i