17C-152 07/05/2010 10:10 413 - 527 -39.7 SEAN JEFFORDS PAGE 01
Beyond Green • I fl 1
13 TOM OS View I I
Easthampton, MA 01
413. 529 -0544
413. 527-3947 fax
FAX COVER
To: Louis Hasbrou «
Fax: 413 -587 -1272
Pages Including cov
July 9, 2010
Good Morning Louis,
I'm sending over the ' about knob and tube wking for a pint* ere seeking
on 96 High Street in
Please call my cell if I I have any questions. 413-588-1988
Thank you!
Have a gnat week
Jae McAuley
,
07/05/2010 10 :10 413 -527 -3947 SEAN JEFFORDS PAGE 02
Property Address: -x-1-1 .-- ar
contractor pri I I
Name: CCoysti--ticsoivG, w-
Address: e4-3
City, state: 111„ . + « I.
Phone: 9 t - ' + L i
Property Owner
Name: 11.
Address:'✓ t1. gf`
City, State: i i u 1 - a MA Q I 0 C #1...
�
I, `"� (contractor) aUttest and affirm that the binding f intend
to insulate does not have a: ' . air (knob and tube) wiring in the spaces to be insulated and
that f have provided the • + owner with a copy of this affidavit.
Contractor signature
Date -7 1c 0
I i11
I I
Property Address:
Contractor
Name:
Address:
City, State:
Phone:
Property Owner
Name:
Address:
City, State:
I, (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
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations The inspection picess re l res that the building department be called to
inspect work at various stages, which include foundation /footings (before backfdl),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
__per_nnits -in- conjunction. to_ thebuilding _permit_issued, and _that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
_ mate
Address of work
location
s
•
The Commonwealth of Massachusetts
`— Department of Industrial Accidents
„, =W ►�=— E1 Office of Investigations •
t om . ; ;1. 600 Washington Street
' Boston, MA 01111
� www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): e e us U AA G (Len Cons vu ct uYl
Address: 1'3 Te f I(&C C Vi e- t)
dt 021 Lt 13 5 29i -05 f
City /State /Zip: ECls� �(1 Gi, � V1 ( K Phone #:
Are yyu an employer? Check the appropriate box: Type of project (required): i'
4. I am a general contractor and I
1. I am a employer with to 6. ID New construction
employees (full and/or part- time).* have hired the sub- contractors
2.0 I am a sole proprietor or partner- listed on the attached shaveeet 7. ❑ Remodeling
ship and have. no ' Ployees sub - contractors h . .8. Demolition
These
woririn for me in an c aci employees and workers'
'; Y aP tY 9. 0 Building addition
[No workers' comp: insurance _ comp. .insurance.:
required] ed 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. -0 1 a a homeowner-doing-all-work — Q-eacers�a e Exercisedtheir__ —1-LO-Phimlaing 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
employees. [No workers' 13. [Other 1►'!S u tit h oY1 A
comp. insurance required} tok tY _(-et I I irl
'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
ZContractors 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
rn ormation.
Insurance Company Name: F 1 W C �. 1 6 vifekS t ru 4 Ya, r kv
Policy # or Self-ins. Lic. #: 00 1 I f 2 L.'s 2. ' Expiration Date: Lt 1 i
Job Site Address: q P I ( J r ) : S ke- i FttX€ vice o M A City /State /Zip:" ) (0 (.o -
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 $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a *+e
of up to $250.00 a day against the violator. lye advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
• enal o perjury that the in .above ulrue.artd_correct_
.
I do _hereby certi under the • .fP 'l ry information provided
f
Signature: Date �P 1O (. _
-
Phone #: 4 t ' '? 19 - if .
... .
Official use only Do nol write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
- - is Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical_ ector 5. Plumbina Ins. ector _
6.
6.Other
Contact Person: Phone #:
A
ti
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
' T
Name of License Holder : s irk. 31 I f {� r S L
License Number
({acc tt(A) 63{11440 Address Expirat Date
1.-k t 'J - 7 2°i -0 SY L-{
Signature Telephone
9.Aegisteredi Homeltitbrove uetitton tar, ., .. E n } ... ,.. Not Applicable ❑
yonc( Sea v1 E i V t ) - 7'i
Company Name Registration Number
- Ver.VraCe ,e i,t S t iv(t tleoi M to t 2111 •2.
Address �/ Expiration to
Telephone '113 521 - c� t(
SECTION 10- 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 ❑
The_curtent_exemption for .`homeowners" was extPrnieri to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner' certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Urdman'OtK State and cat • E . _ • = Laws- Annotated.
Homeowner Signature
r
L ,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition El Replacement Windows Alteration(s) 1/ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0]
Brief Description of Proposed �p
Work: Cet[vio tvi s1Jaft (, n I tv: 0 , ti $(.( t rt ' rx,ucV btt I We-it( , ika2G
Alteration of existing bedroom Yes X No Adding new bedroom Yes x No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a ` if:Nevi, .ijouse andoriadditiontto• exisfiinq housin t,. omplete° °the. fotiowinq:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
L Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , ` O t a - Yt net Std nc , as Owner of the subject
property
hereby authorize
to a on my behalf, in all matters relative to work authorized by this building permit application.
hl-P itAl"
i .? . .t
Signature of Owner Date
I, , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage i
Setbacks Front
Side L.__....,...._, R:.. _.., L:'.m___.__. R
Rear
Building Height
Bldg. Square Footage h"
I Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: i`
(volume & Location) - A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
µ IF YES, date issued:; ry
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 1 YES 0
IF YES: enter Book Pagel µ and /or Document #:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. — Are — t. an ro osed c�iari es to or a rtions o si n intended f`b tTie ro ert YES 0 NO 0
��y P _P,�._� g� s - p P y �
IF YES, describe size, type and location:
E. Will the construction activity disturb {clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO e
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,� , 4 �I,�t1 SW Only k 0 ' A' v a $ r
City of Northampton ;5 o et trf X47 , ,0 '�
Building Department � CkiiiQ� �rr ayl?er�1it is
212 Main Street Se.M 1 p'Av ita it ,.1C,A M i va r ,,
Room 100 W � A 4 , ' I4 4 �4# . ` ;1;
r , yorthampton, MA 01060 Ttivcr00, . tit ott '� � i
phd0 587 -1240 Fax 413- 587 -1272 I of `t s t at �� fig^
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
,/ -
96 111 VI 81f Map Lot Unit
' ''Zone Overlay District
FLOfe ra i, An
Elm St. - District CB District
SECTION 2 -. PROPERTY OWNERSHIP /AUTHORIZED AGENT
. 2.1 Owner of Record:
izoTctorta. 3{ cio kilk Sti-eef I
Name (Print), e Current Ma lg� 5ss�' - ��
O , .in' ick n fl Telephone
Signature 5tLQ �.., 1
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION. 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1 1°0 (a) Building Permit Fee
i V
2. Electrical (b) Estimated':Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total 1 +2 +3 +4 +5 ' i
( ) 1 Zl . u� Che Number v
s
. - This Section Foi Of vial Use Only
Permit Number: Date
.Building Issued:
Signature:
Building Commissioner /Inspector of Buildings:'!' Date
1 t
t f
File # BP- 2011 -0004
APPLICANT /CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544
PROPERTY LOCATION 96 HIGH ST
MAP 17C PARCEL 152 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out .� �{'
Fee Paid �P�'"
Tvpeof Construction: CELLULOSE INSULATION, AIR SEALING,WEATHER
STRIPPING,BASEMENT,WALLS & ATTIC
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 A166/05 Kf /'f rIR f t t
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
41 '7/2110
Signature of Building 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.
t
BP- 2011 -0004
GIS #: COMMONWEALTH OF MASSACHUSETTS
agtBlod 1 152 , ' CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0004
Project # JS -2011- 000004
Est. Cost: $7200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sa. ft.): 10890.00 Owner: STONE BARRY J & ROSEANNA M
Zoning: URB(100)/ Applicant: SEAN JEFFORDS
AT: 96 HIGH ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529 -0544 WC
EASTHAMPTONMA01027 ISSUED ON: 7/9/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CELLULOSE INSULATION, AIR
SEALING,WEATHER STRIPPING,BASEMENT,WALLS & ATTIC
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 7/9/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo