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24A-043 i mass save �> 16 �a.r�, rvn,.;�arinzrrr}clr-aer.•.. ��r PERMIT AUTHORIZATION FORM Karen Laverdiere ,owner of the property located at: (Owner's Name,printed) 175 Jackson St#2 Northampton (Property Street Address) (city) 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. X �`� -r -------- Owner's Signature — �[ Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date a�o QI•. i�7 Far 4;ticc OW f3nlyr 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- 175 Jackson Street, Northampton, MA 01060-1607 TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTION or ALTERNATIVE RECYCLING SIGNATURE DATE June 10, 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: Weatherization- Insulation and Air Sealing Est. Cost: 2000.00 Address of Work: 175 Jackson Street, Northampton, MA 01060-1607 Owners Name: Karen Laverdiere Date of Permit/Application: June 10,2014 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: June 10, 2014 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 Pubfic Saieiv Board of Building Regulations and Standards Con%tructii)n Supervisor _cense: CS-074539 SEAN R JEFFORDS 13 TERRACE VIEW EASTRAMPTONMA 0I027 Commissioner 11128/2014 Off ice of Consumer Affairs and/Us� 10 Park Plaza - Suite 5170 Boston,Massachusetts 02116 Rome Improvement Contractor Registration Registration: 131279 Type: Individual Expiration: 612912014 Tr# 223916 SEAN JEFFORDS SEAN JEFFORDS 13 TERRACE VIEW EASTHAMPTON, MA 01027 Update Address and return card.Mark reason Address for-change- - F Renewal 0. Employment E) Lost Card 3-CA1 0 50MI-04104-G1012i6 Lj Office of Consumer Affairs&Bininen Regulation License or registration valid for individul use only IMPROVEMENT CONTRACTOR before the expiration date. If found return to. , Registration' 131279 Type- Office of Consumer Affairs and Business Regulation Expiration:_6/2912074 6129/-?014 InaWual 10 Park Plaza-Suite 5170 Boston,MA 02116 SEAN JEFFORDS SEAN JEFFORDS: 13 TERRACE\AEW..- EASTHAMPTON,MA-_01 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): BEYOND GREEN CONSTRUCTION /SEAN 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): 1.0 I am a employer with 3 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]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. E]Demolition working for me in any capacity. employees and have workers' 9. E]Building addition [No workers' comp.insurance comp.insurance. required.] 5. E:] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF1 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 WEATHERIZATION employees. [No workers' 13.K Other 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:NorGUARD INSURANCE COMPANY Policy#or Self-ins. Lic.#:SEWC585439 _/_ . Expiration Date:APRIL 21, 2015 Job Site Address:—/^/,5 �Q cks cm Sr� City/State/Zip: �Q � �� o 07 — f(a 07 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 ofperjuEy that the information provided above is true and correct Si ature: Date: 14 Phone#: 413-5290544 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: Sea ,.J n e d-1 (::!-J — 6-7 q 5-3 olW License Number /3 -T-�r��zce_ Vr . ,�asf� �M�_ 11-2-2- z© l Address p Expiration Date � l - 05 Signature Telephone .. _._,, 9 Registered Home Imriravement!C on tra ctor Not Applicable £ 4!- I and G?'r �o�S?�^u i vr� 13 / 7q Company Name Registration Number l3 7�rr�c e_ V/ ��t S f 2- 2 a� Address Sr24 _ Expiration Date �f 3 - Telephone 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...... £ 11. Home Owner,Egemption The current exemption for"homeowners"was extended 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 108.3.5.1. 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 Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors 1 Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other Brief Description of Proposed + A t Work: 1 l��J►.2Y t?ax (M— A C', I ins l �(1Yl. t 'r Alteration of existing bedroom Yes V/" No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet bas If New house and or addition to exisfing'housing,'complete the followlng: 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 L 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 v IT * �e as Owner of the subject property Co ns kac-�7'0' y?hereby authorize to act on my behalf, in all atters relative to work authorized by this building permit application. Signature of Owner Date a uthorized s Owner 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. ns a. e4 r /ete� Co Print Name rj Date Signature of Owner gent ` ^ - Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning T�is column to be filled in by Building Department Lot Size J Frontage Rear Building Height Bldg.Square Footage 01' Open Space Footag % (Lot area minus bldg&paved #of Parking Spaces A. Hasa �pe c�iPerm�/Va�ance/�Find' �. ,= rbeen �sued �n /onthe��? NO 0 DDNTKNOW YES _ IF YES, datpissued: IF YES: Was the permit recorded at the Registry ofDeeds? NO K � DONTKNOYY YES ~= IF YES: enter Book Page end/or Dncument# B. Does the site contain obrook, body of water orwetlands? NO �~��� DONTKNOYY YE� x�� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained _��~\ Obtained v�� Date� �_/ ' . C. Do any signs exist on the property ��� YES �^� NO v��� � )F YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 05— IF YES, describe type > ' ' L- --------------------------- E. Will the construction activity disturb(clearing,gradin ion.or filling)over 1 acre orioit part ofo common plan ' that will disturb over 1acre? YES NO IF thanallo�hamp�onStonn��tar�anogemontPennithnm�hoDPVV)�n»quined �m�` . . l 11, City of Northampton Status ofPermit Pi 7 f Building Department CtrrB Cut/Dri�teu�tay Perrrft# 1 p y � JUN ! 6 2014 x!DI 212 Main Street Se?verlsepticAvaitaFilllty i U Room 100 Wateritle7[A�atla6illty lect�",c; Pl�mbir,P N�Ga,�, orthampton, MA 01060 Two Sets a Structural Plarts .,h , or, rip MA Qtn`PecYion one 13-587-1240 Fax 413-587-1272 PIof/Site Plans Otf�ier 5peolfy r it i t ti"'` ai i APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION Tht seciiorr to be completed by office: 1.1 Property Address. Hj Lot Untt =Zone Overlay District Nor 0VYLP�0 li'l, Nia-, 010&0 - 1(0 0� Elm St_:District' CB.:Dist rict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ��--++ 2.1 Owner of Record: �' �Gt�t( t't etc(_ A V e- Kaare,, H"deAnvi1(e, MA 0103 --1175-2 Name(Print) Curren Mailin Address: � {-��� w ,- _ r �� � �.,� r i c - s37 - 47U? &*AcA ea Sti UTAn�e dQ N 1 Telephone Signature 2.2 Authorized Agent: ,r ©I �e v► erg v) vots 13 T#-rrax,c Vw • Name( K t) / Current Mailing Address: ^Q 51 ivl, I� 4)(02-1 413 529 - b 54A Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION OSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by ermit a licant 1. Building (a) Building Permit Feb 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: �' Building Commissioner/Inspector'of Buildings Date File#BP-2014-1349 APPLICANT/CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (413)529-0544 O PROPERTY LOCATION 175 JACKSON ST MAP 24A PARCEL 043 001 ZONE URB(99)/ 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,AIR SEALING WEATHERIZATION 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 FOL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Demolif lay Signa ure 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. 175 JACKSON ST BP-2014-1349 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A-043 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-1349 Project# JS-2014-002266 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 40946.40 Owner: LAVERDIERE KAREN zoning. URB(99) Applicant: SEAN JEFFORDS AT. 175 JACKSON ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (413) 529-0544 O WC EASTHAMPTONMA01027 ISSUED ON:612312014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION, AIR SEALING,WEATHERIZATION 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 6/23/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner