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PERMIT AUTHORIZATION FORM
I, F— 9 k PlooV , owner of the property located at:
(Owner's Nbme, printed)
2 L._.ira C61*1 ---
(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.
MneKsAignature
2/f 6114
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
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-
25 LINCOLN AVE,NORTHAMPTON,MAO 1060
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 3/22/2014
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggested Affidavit For Homc Improvement Contractor Pemut 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- AIR SEALING, INSULATION Est. Cost: $930.00
Address of Work: 25 LINCOLN AVE,NORTHAMPTON,MAO 1060
Owners Name: ELIZABETH PLOOF
Date of Permit/Application: 3/22/2014
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$ 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: 3/22/2014 Contractor: BEYOND GREEN CONSTRUCTION Reg. # : 1 31 279
OR: SEAN R JEFFORDS
Not withstanding the above notice, I hereby apply for a permit as the owner of the property.
Date: Owner: Tel. #
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super%i%or
License C"74539
SEAN R JEFFORDS
13 TERRACE VIRW s
EASTHAWTONFMA 8
Expiration
Commissioner 11/2812014
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Ro iWalkin: 131279
Type: Indhtidual
EImkMm! 8fA 014 TO 223918
SEAN JEFFORDS
SEAN JEFFORDS _
13 TERRACE VIEW
EASTHAMPTON,MA 01027
Updae AMress ewid eu+card.Mark reeser brchsag&
f:vsrru a s0n4404-oroizte -
❑ Addri a i ❑ Renewal ❑ ampbyn" ❑ Lea Card
d..o� -— Soasn..ow.�aalaE o�. �waca�rrasQa
OW"of Com a AffAn t SWom RegWisfiew Liae e repetrf ..da for lividly"me only
HOPE OrPA 491ENT CONTRACTOR bebre the expikadw deft N bard raters to:
fRspbfllrallotfr 131279 Type: Ogee of CrrwMr Affairs and Basbeos Regaindor
022"12 01 4 ln*.*rd 18 park Phan-Soft 5178
} Bodos,MA 82116
SEAN JEFFII D
SEMI JEFFOR106,.'
13 TERRACE VIEW.• �Q
E/1STIiA1111n1 N. Na now wwaft t siprtare
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
:i Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aanlicant Information Please Print LeLyibly
Name(B usiness/Organizatio0ndividual): 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.[X I am a employer with 4. [] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I 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 or me in an capacity. employees and have workers'
g Y P tY• 9. ❑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 13.�Other 1JVeatflPrization
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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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'cornpensadon insurance for my employees. Below is the policy and,job site
information.
Insurance Company Name: AmGuard Insurance Co. _
Policy#or Self-ins.Lic.#: SEWC469389 Expiration Date: 4/21/2014
Job Site Address: 25 LINCOLN AVE City/State/Zip: NORTHAMPTON,MAO 1060
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 under the pains and penalties of rJ the information provided above is true and correct:
Signature: Date: 3/22/2014
Phone#: 413-529-0544
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority: Building Department
Contact Person: Phone#:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-074539 11/28/2014
SEAN R JEFFORDS
License Number Expiration Date
Name of CSL Holder U
13 TERRACE VIEW List CSL Type(see below) _
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 RoofinR 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
City/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..........QKX No...........❑
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 BEYOND GREEN CONSTRUCTION
to act on my behalf,in all matters relative to work authorized by this building permit application.
3-24• i
e e_ r �c� 6 i a ula�..�e o.��i c�i �!t� �
Print Owner's Name(Electronic Signatu Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the nalties of perjury that all of the information
contained in this application is true and accurate to th y knowledge and understanding.
SEAN R JEFFORDS 3/22/2014
Print Owner's or Authorized Agent's Name(Electronic Signa ) 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/dps
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 halVbaths
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"
_iecr . I . The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CM MUNICIPALITY
R
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
25 LINCOLN AVE,NORTHAMPTON,MAO 106
1.1a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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 es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
ELIZABETH PLOOF NORTHAMPTON, MA 01060
Name(Print) City,State,ZIP
25 LINCOLN AVE _ __ _ 607-624-7299 _
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 13 Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units Other CX Specify:Weatherization
Brief Description of Proposed Work:AlR SEALING MEASURES. DOOR WEATHER STRIPPING.
INSULATE SMALL BUFFER WALL WITH DENSE PACK CELLULOSE.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
i.Building $ 1. Building Permit Fee:$ 55.00 Indicate how fee is determined:
2 Electrical $ IX Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
S.Mechanical (Fire $ Total All Fees:$ 55.00
Suppression)
Check No.� eck Amount: Cash Amount:
6.Total Project Cost: $ 982.96 E3 Paid in ❑Outstanding Balance Due:
File#BP-2014-0992
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (413) 529-0544 Q
PROPERTY LOCATION 25 LINCOLN AVE
MAP 25C PARCEL 058 001 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
T_ypeof Construction: INSULATE BUFFER WALL
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
INFg -IATION 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
Si ature o Buil ing 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.
25 LINCOLN AVE BP-2014-0992
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-058 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-2014-0992
Project# JS-2014-001717
Est.Cost: $982.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 20952.36 Owner: PLOOF JOSEPH&ELIZABETH
Zoning.URB(100)/ Applicant: SEAN JEFFORDS
AT. 25 LINCOLN AVE
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON:312812014 0:00:00
TO PERFORM THE FOLLOWING WORK:I N S U LAT E BUFFER WALL
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 3/28/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner