23D-027 Air\
BEYOND GREEN
C O N S T R U C T I O N
DEBRIS DISPOSAL AFFIDAVIT
IN ACCORDANCE WITH THE COMMONWEALTH OF
MASSACHUSETTS DEBRIS DISPOSAL PROVISIONS OF
MASSACHUSETTS GENERAL LAW 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,
S150A.
FACILITY-
ALTERNATIVE RECYCLING, NORTHAMPTON, MA
CONSTRUCTION SITE ADDRESS-
/RA Sr7 Al/dtr for►, Mass = 06060
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE ata.si r c.e 1 02 2 02-013
NOTICE sam NOTICE
TO - =
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wasmor
EMPLOYEES ! ;, EMPLOYEES
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IMP
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
AmGUARD Insurance Company
NAME OF 111StTRANCE COMPANY
P.O. Box A-H 16 South River Street
Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
SEWC469389 04/21/2013 04/21/2014
POLICY NUMBER EFFECTIVE DATES
FINCK & PERRAS INS AGENCY
6 CAMPUS LANE 413-527-3000
Eastharnpton, MA 01027
NAME OF INSURANCE AGENT ADDRESS PHONE
Sean 3effords
13 Terrace View
Easthampton.MA 01027
EMPLOYER ADDRESS
04/08/2013
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF A:NY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
600 Washington Street
Boston,MA 02111
:.»�' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaulicant Information Coy) Please Print Legibly
Name(Business/Organization/Individual): �' ot�tOk-. • (e e.v Coy) t>G�l Sean Se.. d -
Address: 3 l aXtral_c.A- V i.e t..)
City/State/Zip: E as}kAw.t,4ah, MA Phone#: 4t 3. 52.9. O' 4.4
r 0L02.1
Are you an employer?Check the appropriate box: Type of project(required):
1.Er I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
officers have exercised their 10. Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs J
insurance required.]t employees.[No workers' 13.KOtherWj.kker Inert'
0(l1
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.
iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 1 ^ /�
Insurance Company Name: Avyl ( U AR 1) 1 VlSura ii C. WiPO4 vi J
Policy if or Self-ins.Lic,#: �'jE`(�/G 4(p 9 3$ 9 Expiration Date: 'j 12. 1 /2.0 1:1-
Job Site Address: 14 6 B E 1141 7r-e City/State/Zip:JVOY*a�4. 0/060
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 and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify ander the '' , 1 'nalties of perjury that the information provided above is true and correct
Signature: Date: au Q,.t4-( .17, /3
Phone#: 4 I 3. 52.9 - 0 5 4�- Q
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: S ea-V1 R• 3e -eo rd s CS - 0 7 4 5 3 9
License Number
t3 (e.X race. V('-e�w, East ketw►pion, PIA t ( 2820(4
Address 0(p .7 Expirat ate
4(3- aq-o5J
Signature Telephone
9.Registered Home improvement Contractor: ' Not Applicable ❑
'�ey ov><A G4 re,e to Con s+-r'uc+1 o►n, eciin 3:2-fiarOs 13177C?
Company Name Registration Number
t3 Terr&w View, East kaw•p}t,n, MA c, f zg 20(4
Address b L.O 01 2 Expiration Date
Telephone 4 t! L 3.5 c S"4
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.!.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this apl lication.Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No Q
11. - Home Owner Exeination
The current exemption for"homeowners"was extended to include Owner-oc pied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Dermition of Homeowner:Person(s)who own a parcel of land on which he/$he resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached struptures 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)i 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 Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition El Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors U
Accessory Bldg. El Demolition El New Signs [0] Decks [Q Siding[O] Other
Brief Des Ciption of Proposed &� - � (oVe CO r( I �u
Work: _L ero ve. C- /�t s esAQ lrQ v15 1MQ
O ! 13(ou c lose.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house and or addition to existing housing, complete the following:
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.
I. 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, e.-[*4) T. T 0a5'�S ,as Owner of the subject
property J
hereby authorize 13 exj0nci- G (e eArl Co
VS +r uc--41:°n
to act on m behalf, in all matters relati to work authorized by this building permit application.
lt ,�,jf L- . J ,4) sf a'7),2-O 13
Si na?ry
Own er Date
9
I, S e_CLAel 1Z. . e_��P s , as Owner/: orize•
g tt ii• ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my nowledge
- • •e ief.
Signed under the pains and penalties of-perjury.
Print Name ,
Ai ' ....t._ •�. c91 d---0 ( 3
Signature of Owner/Agent Y Date 4
F, Department use only
D , �� , ( g City of Northampton Status of Permit:
l Building Department Curb Cut/Driveway Permit
1 212 Main Street Sewer/Septic Availability 100
0 2013 Room Water/Well Availability
ty
Electric,Plumbing&Gas In .action Northampton, MA 01060 Two Sets of Structural Plans
Northampton,MA 0', .ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans
11 Other Specify
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
+6,g E Ivy, S free t Map Lot Unit
h(o r f tia vh p -I-o n/ Pl A, 01660 Zone Overlay District
Elm St District GB-District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ke.(fIY I. 'dt9c rs 140 F(vy, Sir) Norfl1armpIw , MA
Name(Pript) Current Mailing Address:
/ 'ei-Y- 1.J ` j (10r S Telephone 4( 3 ' 7-2.7— 33 17
Signature l
2.2 Authorized Agent: 1
Q.t tOy1a (3(e'er, Cnslrt,.ACi� On 13 Tefrrace Vi'u,j, E st 1a�4+, MA
Name(Print) �J , Current Mailing Address:
411... 413 . 5Ac{ - OS 44
Signature Telephone
SECTION 3-ESTIMATED CO TRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fees 00
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection j�
6. Total=(1 +2+3+4+5) ,S I, 4/6 0 — Check Number 'ot 7 (24' 6('�
This Section For Official Use Only TT
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0257
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529-0544
PROPERTY LOCATION 468 ELM ST
MAP 23D PARCEL 027 001 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 '067 Y1/6-6—
Fee Paid
Typeof Construction: AIR SEAL ATTIC&BLOW IN 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:
oved 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 Peiiiut 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 elay
43,"
Sign. e o .ui ding 0 facia 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.
468 ELM ST BP-2014-0257
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-027 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-2014-0257
Project# JS-2014-000424
Est. Cost: $1460.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 6795.36 Owner: RODGERS KEITH
Zoning:URB(100)/ Applicant: SEAN JEFFORDS
AT: 468 ELM ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529-0544 WC
EASTHAMPTONMAO1027 ISSUED ON:8/30/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC & BLOW IN 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 8/30/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner