16C-021 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 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-
361 Spring Street, Florence, MA 01062-9754
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 12-31-13
AFFIDAVIT
Home improvement Contractor Law
Supplement to Permit Application
Suggestcd 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- Insulation and Air Sealing Est. Cost: $3,304.00
Address of Work: 361 Spring Street, Florence, Ma 01062
Owners Name: parol Bishop
Date of Permit/Application: 12/31/2013
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$ 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: 12/31/2013 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. # :
Massachusetts -Department of Public Safety
Board of Budding Regulations and Standards
Con.truction Super%kor
-icense CS-074539
SEAN R JEFFORIDS
13 TERRACE VIEW 4
EASTHAMPTOlf MA 0
Expiration
Commissioner 11128=14
Office of Consumer Affairs and BUsiness Regulation
10 Park Plaza- Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
RepWasbion: 131279
Tvm: Individual
EWVftW' 612912014 Tr$ 223916
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON, MA 01027 — —
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Boston,MA 02116
SEAN JEFFORDS
SEAN JEFFORD.S.
13 TERRACE VIEW
EASTFIAMPTOK MA OQ121-_* Net valid wi bod sipftare
r
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
Applicant Information Please Print Leg=ibly
Name(Business/OrganizatiorOndividual): Beyond Green Construction / Sean R Jeffords
Address: 13 Terrace View
City/State/Zip: Easthampton, MA 01027 Phone#:413-529-0544
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with 3 4. [:] I am a general contractor and 1 6 E]New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 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 and have workers' y E]Building addition
[No workers' comp.insurance comp.insurance.t
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.[)KOther WeatherlZation
comp.insurance required.]
*Any applicant that checks box t11 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'corm.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AmGuard Insurance Co.
Policy#or Self-ins.Lic.#: S EWC469389 Expiration Date. 4/21/2014
Job Site Address: 361 Spring Street city/State/Zip: FLORENCE, MA
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.
7 do hereby certify under the pains and pe s rjury that the information provided above is true and correct,
Sip-nature: Date: 12/31/2013
Phone#: 413-529-0544
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority: Building Department
Contact Person: Phone#:
�awrot
lk
mass save
Sroatgs tYO9''+•-'i!V eISK/ent�•
PERMIT AUTHORIZATION FORM
f? owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
' r
Owner's Sigma We
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-074539 11/2812014
SEAN R JEFFORDS
License Number Expiration Date
Name of CSL Holder
13 TERRACE VIEW List CSL Type(see below) U
No.and Street Type Description
EASTHAMPTON, MA 01027 U Unrestricted(Buildings up to 35,000 cu.ft.
-- R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
413-529-0544 sean @beyondgreen. iz SF Solid Fuel Burning Appliances
I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 131279 6/2912014
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 - 44
City/Town,State,ZIP Tale hone
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..........4:X No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize BEYOND GREEN CONSTRUCTION
to act on my behalf,in all matters relative to work authorized by this building permit application.
S e e- l�b CA - e.r '� OLtk iA r rZa---r ct» 12. 3 t, 13
Print Owner's Name(Electronic Signatur 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 accurate to my knowledge and understanding.
SEAN R JEFFORDS 12-30-2013
Print Owner's or Authorized Agent's Name(Electronic S store) 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"may be substituted for"Total Project Cost"
J0 2 2014
Ei ric,P umbing.moon,MA 010
The Commonwealth of Massachusetts
60
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3¢1 Spring Street, Florence, MA 01062-97 4 _
L l 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)
15 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal 13 On site disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Darol Bishop Florence_, MA 01062-9754
Name(Print) City,State,ZIP
361 Spring Street= _ 413-887-9324 daro1.bishop@gmaiL.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units Other EX Specify:WeatheriZation
Brief Description of Proposed Work?: Attic Insulation measures to kneewall, gable wall and attic
slope with dense pack cellulose Air Sealing, Poly Vapor barrier in.crawl Space,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
i.Building $ 1. Building Permit Fee:$�Qd Indicate how fee is determined:
2 Electrical $ 1%Standard Cityfrown Application Fee
jTotal Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $_
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$ 55.00
Suppression)
Check NoR20 4 Check Amount: 55 Cash Amount:
6.Total Project Cost: $ 3,304.00 ❑Paid in Full ❑Outstanding Balance Due:
File#BP-2014-0767
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416)529-0544
PROPERTY LOCATION 361 SPRING ST
MAP 16C PARCEL 021 001 ZONE URA(94)/WSP(94)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
m li.'on ay
Signature of Building ficial V 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.
361 SPRING ST BP-2014-0767
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C-021 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-2014-0767
Project# JS-2014-001318
Est. Cost: $3304.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 15071.76 Owner: BISHOP DAROL W&MARTHA J
Zoning URA(94)/WSP(94) Applicant: SEAN JEFFORDS
AT. 361 SPRING ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529-0544 WC
EASTHAMPTONMA01027 ISSUED ON:11612014 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# 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 1/6/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner