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10B-065 (4)
J letter 8f0,` 4S i mass save PART��ICIIPP�A'"TING �i3'JUi+„'t;t►urxu��lr�rur�y f.:ti:lar+cy CONTRACTOR PERMIT AUTHORIZATION FORM I, Matthew Thomas ,owner of the property located at: (Owner's Name,printed) 35 Water Street Leeds (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 , -0 Owner's Signature I X1221 �� 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 I �i For Office Use Only 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- 35 Water St. Leeds, MA, 01053 TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTION or ALTERNATIVE RECYCLING "--ig SIGNATURE DATE 4/10/15 AFFIDAVIT , Home Improvement Contractor Law Supplement to Permit Application 5uggosted 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: 35 Water St. Leeds, MA, 01053 Owners Name: Matthew Thomas Date of Permit/Application: 4/10/15 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: 4/10/15 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 ., C1111struction Superl Nor License: CS-074539 SEAN R JEFFORI� ' 13 TERRACE VIEW EASTRAMPTOPFMAi Expiration Commissioner 11/28/2016 /Css Office of Consumer Affairs and B Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 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. C Address J Renewal [] Employment L_[ Lost Card SCA 1 Co 20M-05/11 r�fer+rrrternx[aetrff�r�r l�a [c/rr�ell License or registration valid for individul use onl Office of Consumer Affairs&Business Regulation g y OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 131279 Type: Office of Consumer Affairs and Business Regulation xpiration: 6/29/2016 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 SEAN JEFFORDS SEAN JEFFORDS 13 TERRACE VIEW EASTHAMPTON,MA 01027 Undersecretary Not valid without signature r The Commonwealth of Massachusetts fD Department of IndustrialAccidents H Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 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): 1.0 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. E]Remodeling ship and have no employees These sub-contractors have g. n Demolition working or me in an capacity. employees and have workers' g Y aP tY• $ 9. E]Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.[1 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.E]Roof repairs insurance required.] t c. 152,§1(4),and we have no WEATHERIZATION employees. [No workers' 13.©Other comp. insurance required.] *Any applicant that checks box#I 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 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: 35 Water Street City/State/Zip: Leeds, MA, 01053 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 n l ' of perjury that the information provided above is true and correct. Signature: Date: 4/10/15 Phone#: 413-5290544 f— 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#: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-074539 Yid 7QN 1M 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 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 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 131279 Sean R Jeffords-Beyond Green Construction umber 016 N HIC Co Registrant Name Name or HIC R HIC Registration Number Expiration Date Company 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. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes..........QKX 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 4/10/15 _ Print Owner's Name(Electronic Signature) 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 best of my knowledge and understanding. SEAN R JEFFORDS 4/10/15 Print Owner's or Authorized Agent's Name(Electronic igna Date TES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered 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/des 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 half1baths 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" VJ ( N y o CV.) The Commonwealth of Massachusetts 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 �z One-or Two-Family Dwelling This Section For Official Use Only But ding Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 5 Water St. Leeds MA 01053 1.1 a Is this an accepted street?yes no Map Number Parcel Number 13 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 es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Matthew Thomas Leeds, MA,01053 Name(Print) City,State,ZIP 35 Water Street 413-539-3165 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repah*s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other EX Specify:Weatherization Brief Description of Proposed Work2:JMpgo VF ATTIC I INS[II ATION TO CY)DF AND AIR SEALING MFAS Il R S SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$__6j__Indicate how fee is determined- 2.Electrical $ EX Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All F s:$ 61 S cession Check No Amount: Cash Amount: 6.Total Project Cost: $ 1,000.00 ❑Paid in F ❑Outstanding Balance Due: File#BP-2015-0959 APPLICANT/CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 Q PROPERTY LOCATION 35 WATER ST MAP IOB PARCEL 065 001 ZONE URB000Z THIS SECTION FOR OFFICIAL USE ONLY: PERM_IT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid r BuildingPennit Filled out Q 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 INFO$A4ATION 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 Signat e of Bui ng 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. 35 WATER ST BP-2015-0959 COMMONWEALTH OF MASSACHUSETTS Map:Block: l OB-065 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory: INSULATION BUILDING PERMIT Permit# BP-2015-0959 Project# JS-2015-001862 Est.Cost: $1000.00 Fee: $61.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sa. ft.): 10018.80 Owner: THOMAS MATTHEW DAVID& Zoning: URB(100) Applicant: SEAN JEFFORDS AT. 35 WATER ST A_ pplicantAddress: Phone: Insurance: 13 TERRACE VIEW (413) 529-0544 O WC EASTHAMPTONMA01027 ISSUED ON.•411412015 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 Sianature: FeeType: Date Paid: Amount: Building 4/14/2015 0:00:00 $61.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner