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PERMIT AUTHORIZATION FORM
I, Joseph Tarantino ,owner of the property located at:
(Owne('s Name,printed)
110 N Elm St 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
Owner's Signa re
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:
BEYOND GREEN CONSTRUCTION JUNE 13,2014
Participating Contractor Date
O1
Forks uss Only
Rev. 12132011
AO�N
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,
S 150A.
FACILITY-
ALTERNATIVE RECYCLING, NORTHAMPTON, MA
CONSTRUCTION SITE ADDRESS-
110 NO. ELM ST.,NORTHAMPTON,MA 01060
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 6/13/14
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: 2,300.00
Address of Work: 110 NO. ELM ST.,NORTHAMPTON,MA 01060
Owners Name: JOSEPH TARANTINO
Date of Permit f Application: 6/13/14
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: 6/13/14 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. # :
Massachusetts -Department of Public Safety
Board of Budding Regulations and Standards
Construction Supcn kor
License CS-074539
SEAN R JFFFOW
13 TERRACE VIZW
EASTHAWTOK KA
J.�.. � 4 ""` Expiration
Commissionef 1128/2014
� �fe -�a,m�nio�rrlcuea��t �
Office of C o nsum er Affairs and Business Regulation i
uQe�a
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Rellishab on: 131279
Type: hul ivik u d
E*WW' MAW14 US 223916
SEAN JEFFORDS —
SEAN JEFFORDS
13 TERRACE VIEW.–i
EASTHAMPTON,MA 01027 _ --
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HOME RIPRCVaOIT CONTRACTOR kefem ae data 1f 11111110""*Wu to:
Rispisb>ttiwt: 131279 Typo: Office of Corse ever Affairs and Rusiuus ReMoMioa
6/29rlOtd Indiridral 18 Park PlIm-Sake S170
some,AM$2116
SEAN JEFFORt?S
SEAN JEFFORW
131ERRACE VIEW
EASTHMdPTOK MA 000i2T: IYot vow wifkaat swie"M
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
I Congress Street,Suite 100
4W; Boston,MA 02114-201
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
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.Q I am a employer with 3 4. ❑ I am a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. T ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp.insurance.y
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I. 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.W Other _
comp. insurance required.]
*Any applicant that checks box#1 must also till 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.
YContractors 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:NorGUARD INSURANCE COMPANY
Policy#or Self-ins.Lic.#:SEWC585439 _ Expiration Date:APRIL 21,2015
Job Site Address:
110 NORTH ELM STREET City/StatelZip:_ 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 o at the information provided above is true and correct
Signature: Date: 6/13/14
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 5: 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 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.biz SF Solid Fuel Burning Appliances
1 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 413-529 0544 Email address
Easthampton, MA 01027
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.J 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.
SEE ATTACHED SIGNATURE AUTHORIZATION AFFIDAVIT JUNE 13,2014
Print Owner's Name(Electronic Signature) i Date —
SECTION 7b:OWNEW 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 the ledge and understanding.
SEAN R JEFFORDS 6/13/14
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 rcgistercd 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 Information on the Construction Supervisor License can be found at www.mass.g_ov.idns
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"
JUN 6 2014
The Commonwealth of Massachusetts wrions
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
110 NO. ELM ST.,NORTHAMPTON,MA 01060
LI to 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)
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
N
JOSEPH TARANTINO ORTHAMPTON,MA01060
Name(Print) City,State,ZIP
110 NORTH ELM STREET 413-584-3608 kik63@aol.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ � Repairs(s) ❑ 1 Alteration(.) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other [%Specify:Weatherization
Brief Description of Proposed Work2:IMPRQVF ATTIC INS111 ATION ('EI I 111 OSE 8" AND nFN.I;F
PACK- E, AIR SFAI ING MEASURES, INSTAI I ACCESS
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ I. Building Permit Fee:$_55_Qo_Indicate how fee is determined:
2.Electrical $ 19 Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier_x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAQ List:
5.Mechanical (Fire
Suppression) $ Total All Fqs: 55.00
Check No. &�CheckArnount: Cash Amount:—
6.Total Project Cost: $ 2,300.00 ❑Paid in F—ull—T ❑Outstanding Balance Due:
File#BP-2014-1348
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (413)529-0544 Q
PROPERTY LOCATION 110 NORTH ELM ST
MAP 24C PARCEL 026 001 ZONE URB(99)/M(1)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Al
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION DENSE PACK SLOPE AIR SEALING& INSTALL
ACCESS
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O 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
Demolition Delay
Signature of Building O icial 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.
110 NORTH ELM ST BP-2014-1348
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-026 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-2014-1348
Project# JS-2014-002265
Est. Cost: $2300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sc. ft.): 23391.72 Owner: TARANTINO JOSEPH B
Zoning URB(99 /�1)/ Applicant: SEAN JEFFORDS
AT. 110 NORTH ELM 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,DENSE PACK
SLOPE,AIR SEALING & INSTALL ACCESS
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