29-211 (3) 20 BEATTIE DR BP-2020-0542
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-211 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-0542
Proiect# JS-2020-000931
Est.Cost: $6300.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq. ft.): 17990.28 Owner: REJNIAK DAVID&
zoning: �plicunt: BEYOND GREEN CONSTRUCTION
AT. 20 BEATTIE DR
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 0 WC
EASTHAMPTONMA01027 ISSUED ON:10/28/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 si#"nature:
FeeType: Date Paid: Amount:
Building 10/28/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
cl
m
z+ C X The Commonwealth of Massachusetts
I° Board of Building Regulations and Standards FOR
n r Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
z M Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
K
CD
� r%.) One-or Two-FamilyDwelling
This Section For Official Use Only
o Buil ' ermit Number: Date App 'ed:
Official(Print Name) V
Signature
5ECTI 1:SITE INFORMATION Date
1.1 Property Address: 1.2 Assessors Map&Parcel Numflerss
a C-�� �i, e or• - 1 Oren o.►.,t,w �q
1.1a 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 11) 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:
(Y-.Kr,d `►o`er __ o c ex�Ge M
Name(Print) City,State,ZIP
ao bft;HN e 0c 913 -5 `104
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: C0,3 QS
�fl,n G�tS
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Oficial Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$JL0 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 All Fees: �0
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
i ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) j� C_ �? � ' a 8
SEAN R JEFFORDS l.J lJ J
License Number Expiration Date
Name of CSL Holder
13 TERRACE VIEW List CSL Type(see below)
Type Description
No.and Street U Unrestricted(Buildings up'-to 35,000 cu.R.
EASTHAMPTON MAO 1027 R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413-529-0544 SEANnaBEYONDGREEN BIZ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,G, -7 14
�o 5��
Sean R Jeffords-Beyond Green Construction H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
13 Terrace View s�beyondgreen.biz
No.and Street
Eastham ton.MA 01027 Email address
P 413-529-0544
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 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...........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
to act on my behalf,in all matters relative to work authorized by this building permit application
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under t e pains and penalties of perjury that all of information
contained in this application is true and accurat a best of my knowledge and understanding,
_Sean Jeffords o�
Print Owner's or Authorized Agent's Name(Er6ALC 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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 Let*ibly
Name (Business/Organization/[ndividual):_bLxA 6 (' Cd G tf-co
Address: ) 3 lc� 05 CQ V 1 e L sJ 1
City/State/Zip: �—_a 1- C'LXY-- A Phone#: 141 - J a/�- fl\
Are you an emplover?Check a appropriate box: Type of project(required):
L�I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑1 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.F_1 t am a homeowner doing all work myself.[No workers'comp.insurance required.]f
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.F]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
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. h`1
152,Z 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 sub-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. N C
Insurance Company Name: l JOrLl�.11^(� n Jux G—A o
Policy#or Self-ins.Lic.#: S j� (� :7 Expiration Date: — li _0
,, �
Job Site Address: �o Re0 I f— Or• City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 r !ties of perjury that the information provided above is true and correct.
Signature: Date: 10 a
Phone#:
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#:
AFFIDAVIT
Home fmorovei7 nt C;cmtractor tea:
Supplement to Permit Apvhcauo
SvggiatciAfrt6a^.e:'4.rscrr_it� �:c.atCantrs ta:R,a:}spniicaciu:
For E0MuCe Use On!--
Pe nlit No.;
'lee t si: il, TIJ-quir3b t—ht lbr: r'lr''CansLmction. a;wratdon, ra..novarion, r,.-pair, F:3`:i6r.T 'z&ti3U. CorivmsioZ'<.
it�rrovemer?t=remcrva.i or demoii�:.fvn or�e construc?ional of an�dditioz^ "�� an=T qtr-existing�swner oeclipieu
buidmg runtain:ng at i�st oae but:�a inofr tl�four il�r.-lliztg moi[,a:_c�st,^.ac�es:�hicr a.�adjacen=#v s�=cam
: resicien�evI builciin�b��.:1F:e wt%re'<:'.ati c'.ii+,f`.`,II2 cC ).TS.4'.'iii�'i�..Tl71it?CR�L'I�tlJitSy A.it;i34�T"r�'I�Y►EJL�2Cr'C4ti3t13ru172v'A•tS. �
ype of��ark: 'PSL Cost:
ddress o3' t ark a Y M'
Dale of Permit I App?ieation: — �����it)
??ereny ce_•tify that:
`_stM"'rA is not recr-imd forte fOIT(,\W;tag reason(s):
Work exclude:by law
job uuder$500-00
EuMing not ovrr�ar occupted I
Owner ppffling own L£rmit' �
3t}iBT(specie)
NoLice is hereby given that: 1
O YJ�v Rs 'LIt LT'�EG THEIR OW,, i'I;�.M1 i c,;Fc s7FALIP+?Ei WI CH I�I�tREUI�iERED z•O?VT2 �T:h
FOR APPLICABLE HOME€MPROVEVENTI IWORK nQ NOT HAVE ACt'ESS TO THE
:kiZBI-,-RA"I'_IGN PROC-RAN4 C)R GF ARA.N'I-Y FC.TND F±N?-IER FBF;L^ 7442A.
f
I � !
sigacd•,:iter Penalties of Pe.jury:
I hereby apply for a penrAt x,, 4e agent of the uwn-er:
Date: Co-,IntC}r: $C-Yf tlkL)+�REEAi CGNS i RUl� d,�?{_ -13 1279
OR: SEAM!R JE=POPOS
o+w-tasta*:ding the above notice,Frnpropyilyv � saaerty.
Tel.
Hatt: Owner: — - - —
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Commonwealth of Massachusetts
®. Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
3
CS-074539 Expires: 11/2812020
SEAN R JEFFORDS
13 TERRACE VIEW
EASTHAMPTON MA 01027
Commissioner
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C✓ �Qi �f���/��t#i{���'Q�lilG ��L/�+��'�.'���Pi2rirF�•
Office of Consumer Affairs and Business Regulation,
One Ashburton Place - Suite 130!
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Corporation
Registration: 191746
BEYOND GREEN CONSTRUCTION INC. Expiration: 0510912020
13 TERRACE VIE:ti
EASTHAMPTON,MA 01027
Update Addrea3 and Return card.
A 1 20S1-05!17
::
_5irr 't'r�u»:rt+rnrn��r,."'llrz:.;u:•�:i.a//"
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR ,Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
,91745 05/09/2020 One Ashburton Place-Suite 1301
BEYOND GREEN CONSTRUCTION INC. Boston,MA 02108
SEAN JEFFORDS \E=Gv
13 TERRACE VIEW Not valid without signature
EASTHAArIPTON,MA 01027 Undersecretary
AdF
'BEYOND GREEN
C 0 N S T R U C T ' 0
DEBRIS DISPOSAL AFFIDAVIT
N ACCORDANCE WITH THE ^0?,-4M011WEALTH OF
iASSi?C H{ SETT-, DEBR S DISPOS�YL �RO�jsS'O�fS OF
MASSACHUSE"S GENERAL 1—,kW CHAP ER 40s SFC:FION
Ar A CONDITION OF BUILDING €'E!?�;�" NUS*`:BES
FOR DEMOLITION WORK IS T±AT s HE DEBRIS
RESULTING FRt-),M TH15 NORM SHALL 3E REM MED FROM
SITE AND DISPOSED OF IN A PROPERLY LICENSED SO; ID
WASTE D71SPOSAL FACT TTY AS DEFINED BY MGL Cii1:
3150A.
`ACIL.:1 t ;-
ALTERNATIVE RECYCLING, MORTHAMPTONF MA
ION SITE ADDRESS-
EL
afenC
_ BE DISPOSED AND TRANSPORTED BY-
EYOND GREE! CONSTR;iCTION or
;kLTERNATXVE RECYCL!ENG
SIGNATURE --
DATE
AWN Permit Authorization
BEYOND GREEN
CONSTRUCTION Form
"LEADERS IN ENERGY EFFICIENCY"
Job number: ?3y S Customer: ,�e�h,G (t
owner of the property located at:
(Owner's Name,printed)
C�, eccsc T , j- . I M 1A , _
(Property Street Address) (city)
I hereby authorize Beyond Green Construction to act on my behalf and obtain a building permit to
do work on my property.
Owner's Signature:
Date:_ '��/_ 1T_
Beyond Green Construction 13 Terrace view Easthampton, Mass. 01027. 413-529-0544