24A-170 OWNER AUTHORIZATION FORM
l
(Owner's Flame)
owner of the property located at
(Propeq Address)
E�:tl,Aw\
a �a
(Property Address)
hereby authorize
(S r)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
Owner's Signature
q-
Date
AV *
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 TH15 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-
14 JACKSON ST. NORTHAMPTON, MA, 01%
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 4/3!15
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 Est. Cost: 1,000.00
Address of Work: 14 JACKSON ST. NORTHAMPTON, MA, 01%
Owners Name: KRISTEN KELLY
Date of Permit/Application: 4/3/15
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: 4/3/15 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 Building Regulations and Standards
Construction Supen-Isor
License: CS-074539
SEAN R JEFFORIQS
13 TERRACE VIEW
EASTHAMP PON M f
4
& Expiration
Commissioner 11/28/2016
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 131279
Type: Individual
Expiration: 6/29/2016 Tr# 254174
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW --- - ----
EASTHAMPTON, MA 01027 - --- - - - ----
Update Address and return card.Mark reason for change.
Address ;` Renewal [-] Employment ❑ Lost Card
SCA i v 20M-05/11
%fieonznrnrrcoe(�lt rfT�a ac/rufefYi License or registration valid for individul use only
Office of Consumer Affairs&Busifiness Regulation g Y
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
09egistration: 131279 Type: Office of Consumer Affairs and Business Regulation
xpiration: 6/29/2016 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
SEANJEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON,MA 01027 Undersecretary Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
a Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
�M 5 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. E] 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, F]Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp.insurance comp.insurance)
required.] 5. EJ We are a corporation and its 10.0 Electrical repairs or additions
3.[1 I 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,§1(4),and we have no WEATHERIZATION
employees. [No workers' 13.0 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: 14 JACKSON STREET 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$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 pain nd ties of perjury that the information provided above is true and correct
Signature: Date: 4/3/15
Phone#: 413-5290544 �r'
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 xvmQyj $11/28/2016
SEAN R JEFFORDS License Number Expiration Date
Name of CSL Holder
13 TERRACE VIEW List CSL Type(see below) U
No.and Street Type Description
EASTHAMPTON, MA 01027 U Unrestricted(Buildings to 35,000 cu.ft.
R Restricted I&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
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 131279 6/29/2016
Sean R Jeffords-Beyond Green Construction H
HIC Company Name or RIC Registrant Name IC Registration Number Expiration Date
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.$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 FORM 4/3/15
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERi 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 th y knowledge and understanding.
SEAN R JEFFORDS 4/3/15
Print Owner's or Authorized Agent's Name(Electronic Si 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 registercd 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 basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hall7baths
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"
n The Commonwealth of Massachusetts
=� Board of Building Regulations and Standards FOR
� MUNICIPALITY
c0 Massachusetts State Building Code,780 CMR USE
\l r I Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
CU
One-or Two-Family Dwelling
o This Section For Official Use Only
ilding Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
14 JACKSON ST NORTHAMPTON MA 01060
1.1a 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)
15 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:
Zone: _ Outside Flood Zone? Municipal On site dis osal stem 13 Public❑ Private❑ Check if es❑ p
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: NORTHAMPTON, MA, 01060
KRISTEN KELLY
Name(Print) City,State,ZIP
14 JACKSON STREET 215-527-7699
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other IX Specify:Weatherization
Brief Description of Proposed Work2: IMPRCIVF ATTIC INN II ATION TO CODE AND AIR SEALING
MEASI I R E S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:S__55__Indicate how fee is determined:ig Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All F s:$ 55
Suppression)
Check N . k Amount: Cash Amount:
6.Total Project Cost: $ 1,000.00 ❑Paid in ❑Outstanding Balance Due:
File#BP-2015-0938
APPLICANT/CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 Q
PROPERTY LOCATION 14 JACKSON ST
MAP 24A PARCEL 170 001 ZONE URA000)/
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
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
INF9R,NATION 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
of ' lay
Sig o ui n 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.
14 JACKSON ST BP-2015-0938
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 170 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-2015-0938
Project# JS-2015-001816
Est.Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sa. ft.): 8189.28 Owner: KELLY KRISTAN
zoning: URA(100)/ Applicant: SEAN JEFFORDS
AT. 14 JACKSON ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON:41712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC 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 Shinature•
FeeType• Date Paid: Amount:
Building 4/7/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner