32A-191 (3) 50 PHILLIPS PL BP-2019-0773
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 32A- 191 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-2019-0773
Project# JS-2019-001275
Est.Cost: $6829.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sa.ft.): 7492.32 Owner: LEWIS BENJAMIN
Zoning:URC(100)/ Applicant. BEYOND GREEN CONSTRUCTION
AT. 50 PHILLIPS PL
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413)529-0544 Q WC
EASTHAMPTONMA01027 ISSUED ON.11712019 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEALING, LOOSE BLOWN INSULATION IN
ATTIC FLAT
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 1/7/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair, r 1:Vised Mar 2011
One-or Two-Family Dwellin C
This Section For Official Us Oni
Building Permit Number: 2aAppliec
19Building Official(Print Name) Signature DEPT.OF 81J LD-NO INSPECTIONSate
SECTION 1:SITE INFO TIONNORTHAMPTON.MA01060
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
50 NknsPl NtX+h(Itn ,>4 l�l
1.1 a Is this an accepted street?yes no L l Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use 1 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. Owner'ofRecord:
Name( t) City,State,ZIP
50 Ph( 91 au
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ I Addition ❑
Demolition ❑ I Accessory Bldg.o I NumberofU ' Other Specify: Gu2CL4-hC(YZC(zI_an
Brief Description of Pro sed Work2: Gt E,3ULA 1'0 a71
G.
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 Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total AllFee*$
Check NOA Check Amount: Cash Amount:
6.Total Project Cost: $ g .3� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
>1 i 0-&®6--�wdc RA 2
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �1 CJ_ �� cJJ Ca + � o�g 11
SEAN R JEFFORDS II +
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
13 TER, VIEW: Type Description
No.andStreet°. U Unrestricted(Buildings up to 35,000 cu.ft.
EASON.MA 01027 R Restricted 1&2 FamilyDwelling
TI-1�AMP'It �
City/To S e, M Masonry
ZIP '�
' RC Roofing Covering
a WS Window and Siding
SF Solid Fuel Burning Appliances
413-529-0544 SEANQrrBEYONDGREEN.BIZ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) {9 i _7L/
7 t`, � 5 f C, J6
Sean R Jeffords-Beyond Green Construction HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
13 Terrace View sean aQbevondgreen.biz
No.and Street Email address
Easthampton.MA 01027 413-529-0544
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.5 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 FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to authorized by this building permit application
Print Owner's Name ectronic ) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
i
By entering my name below,I hereby attest under the nams and penalties of perjury that all of the information
contained in this application is true and a e st of my knowledge and understanding
Sean Jeffords
Print Owner's or Authorized Agent's Name(Electroll 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.m4qL.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 Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leidbly
Name (Business/Organization/Individual):/QnU re h o otl, fttuC.71Un
Address: 3 '"T—e r 1'0 U V^f b_ J
�
City/State/Zip: CO-WiM r\ Phone#: L41 3-5aq--CS S q q
Are you an employer?Check the appropriate box: O l(3Gc — Type of project(required):
1.Q1 am a employer with C4._.etnployees(full and/or part-time).* 7. ❑New construction
2.E]I am a sole proprietor or partnership and have no employees working for me in 8. [:]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.F1 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]f
10[]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.g Othe
6Q we are a corporation and its officers have exercised their right of exemption per MGL c.
154§1(4),and we have no employees.[No workers'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 subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation Insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: IUO G Q�t�Ci� r h
Policy#or Self-ins.Lic.#: S W e C 70a)5 1 Expiration Date: -c;D
Job Site Address: SU Q !\,\ City/State/Zip: N U QLa "Typ /M 0%C)(,00
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire on date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable by 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.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 pev ti ury that the information provided above is true and correct
Signature: Date:
Phone#:
x
n
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermittLicense#
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#:
i
l
tY
i
.... . _ ._.... ....._. ... . ..
i
. Cormionwealth of Massachusetts
Division of Professional Licensure
Board of Building Re ulations and Standards
Cons rp rvisor
CS-074539
W }
ires: 11128!2020
J. i
SEAN R JEFFORDS #
13 TERRACE* S r t
EASTHAMPTONA66
,0 �'•
'1 Ctlti'�•t-il�'�
CommissionerL/^"
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Corporation
BEYOND GREEN CONSTRUCTION INC. R xprRHOM 805/W202020Z0
191746
13 TERRACE VIEW FIrRion
EASTHAMPTON,MA 01027
upaaec address and Ratan card.
!`1/n�nrxwr+rrrreal��n
Owe of Consumer Affairs&Bus
HOME IMPROVEMEW Regfstrstion valid for individual use only
TYPE:Corporation before the expiration date. it found return to:
Office of Consumer Affairs and Business Regulation
191746 05/0012020 One Ashburton Place-Suite 1301
BEYOND GREEN CONSTRUCTION INC. Boston,MA 02108
SEAN JEFFORDS
13 TERRACE VIEW Not valid without signature
EASTHAMPTON,MA 01027 UndemwretKy
AF1 L i�4 T,
SUDlament to PC-.Mut Amhcad;; .
jr Office Use
9
}`Z i'R} ruuquirob :LLL€! thr. 1-'mL.titinaftf3isi on, aiteration, i s� ovwon, rep&, smad1.rLi izat1on, fi.(32xverslo i_ }:
ullprovemen�removal or demoli on or dhe consttuctional of an addition to any pre-existing owner occupied
building ci;utaining at!east one but no moA--don faur dweRiug unit,or to strsact:ros iqInich are adjacent to�tc}4 +
sauersce Or builcLingrP be done bytainexceptions,along iii h cutter iwoquil�.nla;.il'+
;+
Vk�QC9 d
':.sv;zners ,'ase: r
Dam of Perit i Application: _ t
%Voikexcluded by law
ab un&r$500.00 i
`thL 4.Sp�CiE'7r
vot ce l-S reby given that: j
.k
OWNERS
PLTL 3NG THM OWN, PERMITOR DiLI, £i Wj.�Lt3 I.-N-REGI S T±E RED CO-W,
nT ORS
FOR APPLICABLE HOME IM-PRM�ItHMEEW
Wf)RK DO NOT HAVE.AL—,CB',-%S TO THi � It
t
=.paed of Penalties of petwy: I
!ilexeb_'v apply fe a permit as the agent of the aw-ner:
Data: _l v �79
TO
aui-did�$"a ye ab—ve notice, I he �t�,L`apply fS'Ji a peer,t aF I-he tT?Zer O�€�fC Pi flP i Y.
BEYOND GREE
DEBRIS DISPOSAL AFFIDAVIT
TN ACCORDANCE VVITri ^�•t 401,11}r1 EALTH OF
MASSACHIUSEETYS DEBRIS D_SPI,,-SAL PRC?t S;0NS
MASSACi-USER S GENERAL LAW Cr>APTER 40, SEC r'Ceti
Sot A CONIDITION OF BL'ILMLNG PrPMZ7r J2="
FOP, MEM OL.I s N WORN IS T t AT T E Dr-5PI-
RESULTING FRS,-)M T1,1 5-e WORK 5XIA' ? LF 'ZPMOVr.-D FIFO:
'.
SITE AND DISPOSF;I OF IN A PROPERLY ll-C-ENSED SOLID
WASTE DISPOSAL FAC-LITY' ;=-S DEF NTED 3'1'7 NIOGL �.l-'.
ALTERNATIVE RECYCLING1 NORTHAMPTON, MA
_✓'S-FRUCTION SITE ADDRESS-
p/
on
" SE DISPOSED AND TRANSPORT ED BY-
3EYOND GREEN CONSTRUCTION �.
SIGNATURE
DATE
City of
Vi.�SScZChuSEitS
v
t, tDEPMU'lWa OF Bi3"_.MING MFSPWT.-40RS
212 Main Street a Municipal Ruildirng
" _ 1�SDS�'18ID�tC17r � O1❑6O 4•S 4Ti 17t4�
Propeny Andress: 50 �V)'mw S
�ontrac�oP
Name: r-e-on
Address: �_�J � ff r d e V3 j
City, State:
Phone:
Properly Ovil eF
(Mame:
Address: '50
City, State: (tel c,LD
1, (conti
dor)attest and arm 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 aiddavit.
Contractor signature
Cate 1 � L4