24A-120 (2) '°°
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mass save" =R
PERMIT AUTHORIZATION FORM
I, Jeff Zeaiger ,owner of the property located at:
(Owner's Name,printed)
34 Calvin Ter 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 per 't to perform insulation and/or weatherization
work on my property. `
X
Owner's Signature
Date
FOR CS6 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 OCTOBER 20, 2014
Participating Contractor Date
afro
For offike use My
Rev.12132011
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 buildings be done by registered contractors,with certain exceptions,along with other requirements.
Type of Work: MASS SAVE WEATHERIZATION Est. Cost: 4,000.00
Address of Work: 34 CALVIN TER. NORTHAMPTON, MA, 0106
i
Owners Name: JEFF ZESIGER
Date of Permit/Application: 10/21114
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 j
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: 10/21/14 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.#
AgF\
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-
34 CALVIN TER. NORTHAMPTON, MA, 010fi
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 10/21/14
Massachusetts -Deoai7Tne�,! D; DUbiiC Safety
Board of Building Req'A,-1"C,Is Ind Standards
tense CS-074539
SEAN R JEFFORDS
13 TERRACE VIEW
EASTRAMPTONMA 07.027
11128/2014
14 r7V/e
j
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02 116
Home Improvement Contractor Registration
Registration 2 9
Type.! 1 l
In
Expiration: 6/ 9/2016 Tr# 254174
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON, MA 01027
Update Address and return card.Mark reason for change.
SGA 1 20M-05/11 Address ---i Renewal Employment Fj Lost Card
Office of Consumer Affairs&Busifiess Regulation License or registration valid for individul use only
IN;P�;=4,VOME IMPROVEMENT CONTRACTOR before the expiration date. If found return tol
egistration: 131279 Type: Office of Consumer Affairs and Business Reg lation
��xpiration: 6/29/2016 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON,MA 01027
4-
Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite.100
h.
Boston.MA 02114-2017
www massgov/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.R 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
1❑ 1 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 Y 9. ❑Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work � g p
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' I3.❑Q Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
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: 34 CALVIN TERRACE 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 S 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$250.04 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 e i of perjury that the information provided above is true and correct.
Signature: Date: 10/21/14
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 y
List CSL T ( w)see below) U'
13 TERRACE VIEW � _
No.and Street Type Description
EASTHAMPTON, MA 01027 U Unrestricted Build' s up to 35,000 cu.ft.
R Restricted 1&2 FamJly 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 6/29/2016 XOMUM
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.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failwv to providc
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........Q(X No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHIBN
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. T
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby attest un yth s and penalties of perjury that al l of the information
contained in this application is true and acc tc t of my knowledge and understanding.
SEAN R JEFFORDS 10/21/14
Print Owner's or Authorized Agent's Name(Electron 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 rcgistcrcd in the Home Improvement Contractor(141C)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 ww4.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attic� 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_ i Number of decks/porches
Type of cooling system Enclosed _Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
MAP 24A PARCEL 120 001 ZONE URA(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
Typeof Construction: INSTALL ATTIC&RIM JOIST INSULATION&AIR SEAL
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
INFOR TION 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
e o TMlay
Si e in f cial 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.
34 CALVIN TER BP-2015-0467
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 120 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-2015-0467
Project# JS-2015-000896
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 8494.20 Owner: MILLER DOREEN J&JEFFREY A ZESIGER
Zoning. URA(100) Applicant: SEAN JEFFORDS
AT. 34 CALVIN TER
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON.1012812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & RIM JOIST INSULATION &AIR
SEAL
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 10/28/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner