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23C-065 (5)
l u i f ��.�r lurruY:r t a' mass save PAFNTRA TOR t I PERMIT AUTHORIZATION FORM I, Marsha Leavitt ,owner of the property located at: (Owner's Name,printed) 1 113 Bliss St Florence )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. Xx z1XI If Owner's signature / Date FOR CSG OFFICE USE ONLY { I Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: BEYOND GREEN CONSTRUCTION JUNE 24, 2014 Participating Contractor Date Cif`a For Office use Only Rev.12132011 i 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- 113 BLISS STREET, FLORENCE, MA 01062 TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTION or ALTERNATIVE RECYCLING SIGNATURE DATE 5/14/14 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application Suggested Affidavit For Horne 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: INSULATION & AIR SEALING Est. Cost: 5,000.00 Address of Work: 113 BLISS STREET, FLORENCE, MA 01062 Owners Name: MARSHA LEAVITT Date of Permit l Application: 5/14/14 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: 5/14/14 Contractor: BEYOND GREEN CONSTRUCTION Reg. # : 1 31279 OR: SEAN R JEFFORDS Not withstanding the above notice, I hereby apply for a permit as the owner of the property. Date: Owner: Tel. # : The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a I Congress Street,Suite 100 f°4K Boston,MA 02114-2017 www mass.govldia 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.© I am a employer with 3 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.0 i am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working or me in an capacity. employees and have workers' g Yt 9. �Building addition [No workers' comp. insurance comp.insurance. required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,X1(4),and we have no WEATHERIZATION employees. [No workers' 13.0/ Other comp. insurance required.] 'Any applicant that checks box 41 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 isproviding 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: 113 BLISS STREET City/State/Zip:_ FLORENCE, MA 01062 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 a en f perjury that the information provided above is true and correct. Signature: Date: 5/14/14 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: SEAN JEFFORDS CS-074539 License Number 13 TERRACE VIEW, EASTHAMPTON, MA 11-28-2014 Address Expiration Date 413-529-0544 Signature Telephone III 9.Realstered Home Improvement Contractor: Not Applicable ❑ SEAN JEFFORDS- BEYOND GREEN CONSTRUCTION 131279 Company Name Registration Number 13 TERRACE VIEW, EASTHAMPTON, MA 01027 6/29/2014 Address Expiration Date Telephone 413-529-0544 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....... IX No...... ❑ 11. - Home Owner Exemption 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 Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[0] Other(ml Brief Description of Proposed Work: WEATHERI7ATION-INSULATE SIDE WAILS AND ATTIC,AIR SEALING MEASURES.INSTALL ATTIC VENT,CRAWL SPACE INSULATE&VAPOR BARRIER. Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet 6a.H New house and or addition to existina housing,complete the foilowina: 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 1, MARSHA LEAVITT 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. SEE ATTACHED SIGNATURE AFFIDAVIT JUNE 24, 2014 a ture of Owner Date I, SEAN JEFFORDS as Owner/Authorized 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. SEAN JEFFORDS Print Name JUNE 24, 2014 Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: Rear Building Height Bldg.Square Footage Open Space Footage % (fart area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'f KNOW Q YES Q IF YES: enter Book . Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW @ YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only of Northampton Y p utatt�s�o�Peny4#: Bu ding Department CurbCsrintwayPwmlt �nspecUo 2 Main Street Ser rJ , A tl ity" 0 Bobo Room 100 WateriWeN Availabllitty, P`u�"q�nco�^MP SNed"'140�t�am� Northampton, MA 01060 Two 5ats of Murat Fs phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans tither 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 113 Bliss Street Map Lot Unit Florence, MA 01062-2605 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: MARSHA LEAVITT 113 BLISS STR., FLORENCE, MA Name(Print) Current Mailing Address: 413-320-3646 SEE ATTACHED PERMIT AUTHORIZATION Telephone Signature 2.2 Authorized Agent: 13 TFRRAC;F VIEW EASTHAMPTON MA 01027 Name(Print) Current Mailing Address: 413-529-0544 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection At Q At 6. Total=(1 +2+3+4+5) 5,000 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1393 APPLICANT/CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (413) 529-0544 Q PROPERTY LOCATION 113 BLISS ST MAP 23C PARCEL 065 001 ZONE URA(100)/WSP(l00)/S 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& WALL 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION 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 D litio De or Si—I 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. 113 BLISS ST BP-2014-1393 C•IS#: ' COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C-065 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-2014-1393 Project# JS-2014-002357 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 111949.20 Owner: LEAVITT MARSHA Zoning: URA(100,/WSP(100,/SR(o) Applicant: SEAN JEFFORDS AT. 113 BLISS ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (413) 529-0544 O WC EASTHAMPTONMA01027 ISSUED ON:612612014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & WALL 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: FeeTybe: Date Paid: Amount: Building 6/26/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner