31B-164 (3) AdFN
BEYOND GREEN
CONSTRUCTION
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-
149 Elm Street, Northampton, MA 01060
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 3/3/2014
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggested 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: Roof Repair. Insulation&air sealing preventive measures. Est. Cost: $6,500.00
Address of Work: 149 Elm Street, Northampton, MA 01060
Owners Name: Alan Berkenwald
Date of Permit/Application: 3/3/2014
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: 3/3/2014 Contractor: BEYOND GREEN CONSTRUCTION Reg.# : 131 279
OR: SEAN R JEFFORDS
Not withstanding the above notice, I hereby apply for a permit as the owner of the property.
Date: Owner: Tel.# :
fl
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen i%or
License CS-074M
SEAN R JEFFOW
13 TERRACE VE9W
EASTHAMPTONMA
Expiration
Commissioner 111281MAll
er Affairs and 1Tusmess ation
Office of Consumer Regal
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Repisbaftx 131278
TYPO: N►dfAhw
EX*Wm.,., Bf1M14 TIS 223918
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
E ASTHAMPTON,MA 01027
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SEMI JEFFORDS
SEAN JEFFORQS_'_
13 TERRACE VfE.11r.•
EASTHAtdPT K W AO0291-., Nat vM"wins"dpabam
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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
Alnlalicant Information Please Print Leg=ibly
Name(Business organization/lnaividuai): 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.EX 1 am a employer with_ 3 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).; have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g• E]Demolition
working or me in an capacity. employees and have workers'
g Y aP h'• 9. E]Building addition
[No workers'comp.insurance comp.insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.Q Plumbing 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 worker;' 13.[X0tlter Weathe�-ization
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 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. v _
Policy#or Self-ins.Lic.#: S EWC469389 Expiration Date: 4/21/2014
Job Site Address: 149 Elm Street _City/State/Zip: Northampton, MA 01060
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.
1 do hereby certify under the pains and penalties of perjury dW the information provided above is true and correct
Signature: Date: 3/3/2014
Phone#: 413-529-0544
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: PermitlLicense#
Issuing Authority: Building Department
Contact Person: Phone#:
scan0001Jpg 1,700x2,338 pixels 3/5/14 1:34 PM
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-074539 11/28/2014
SEAN R JEFFORDS
License Number Expiration pate
Name of CSL Holder U
13 TERRACE VIEW List CSL Type(see below)
No.and Street -�—_M Type Description
EASTHAMPTON,MA 01027 U Unrestricted(Buildings to 35,000 cu.R
-__— _ _ R Restricted t&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS window and Siding
413-529-0544 sean @beyondgreen.biz SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 131279 6/29/2014
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 413-529-0544
6tyrrown,State,ZIP __. Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.3 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.....-. -CXX No...........0
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.
Print Owner's me(Eleca6mc Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the 390"s of petjury that all of the information
contained in this application is true and accurate to th ledge and understanding.
SEAN R JEFFORDS 313/2014
Print Owner's or Authorized Agent's Name(Electronic 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.mass.gov;oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
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"
http://web.maii.comcast.net/service/home/-/scan0001.jpg?auth=co&loc=en_US&id=566903&part=2 Page 1 of 2
MAR 1 0 2014
The Commonwealth of Massachusetts
*c F �._ - tion- Board of Building Regulations and Standards FOR
F J 1 Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Pennit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Fmnily Dwelling
This Section For Official Use Onl
Building Permit Number Date Applied:
Building Official(Frio ame) Signature Date
SECTIO :SITE INFORMATION
1.1 Property A dress: 1.2 Assessors Map&Parcel Numbers
149 ELM STR N RTHAMP_TON,MA _
I.In Is this an acre street?yes no Map Number Parcel Number
13 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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes13
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owners of Record: NORTHAMPTON, MA 01060
ALAN BERKENWALD
Name(Print) City,State,ZIP
149 ELM STREET 413-586-7440 alanadb@comeast.net
No.and Street Telephone Fanail Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check an that apply)
New Construction 0 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition 0
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other 1X Specify:Weatherization
Brief Description of Proposed Work:
Repair roof damage caused by ice damming. Install ice shield.
Remove and rewire knob&tube Repair and install incuhtion and air sealing measures
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itern Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 6,500.0 1. Building Permit Fee:$,j5,0D_Indicate how fee is determined:
2.Electrical $ 11 Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.PIumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$ 55.00
Suppression)
6,500.00 Check Check t Cash Amount:
6.Total Project Cost: is ❑Paid in Full 0 Outstanding Balance Due:
File#BP-2014-0938
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (4%529-0544
PROPERTY LOCATION 149 ELM ST
MAP 3 1 B PARCEL 164 001 ZONE URB(100)//
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM PILLED OUT
Fee Paid
Buildin Permit Filled out
eT-
Fee Paid
Typeof Construction: REPAIR ROOF&INSULATION FROM ICE DAMMING Q 16 13 c/G r
New Construction
Non Structural interior renovations
Addition to Existing
AccessoLy 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
INFgjjMATION PRESENTED:
I 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
olit' Delay
C3-6
Sign re of Build g Offificiaf 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.
149 ELM ST BP-2014-0938
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 164 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0938
Project# JS-2014-001622
Est.Cost: $6500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 16378.56 Owner: BERKENWALD ALAN
Zoning:URB(100)/ Applicant: SEAN JEFFORDS
AT. 149 ELM ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON:311112014 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAI R ROOF & INSULATION FROM ICE
DAMMING - REAR OF BUILDING
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 3/11/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner