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PERMIT AUTHORIZATION FORM
I, THOMAS SCHIFF ,owner of the property located at:
(Owner's Name,printed)
203 Sylvester Rd FLORENCE
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy rvices Program assig ed Participating Contractor
listed below to act on my behalf and o1b a b ilding per o pert m insul i nd/or
weatherization work on my property.
X
Owner's lure
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
Ei °
For Office U.2a Only
Rev. 12132011 T
�- City of Northampton
r Massachusetts F ��
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: l yc'' frr- IBC CSI :E'o t e n a m a
Contractor
Name: Cfan c nn t r uc-ii 0 n
Address: 13 In ct^,,�LC U i c�
v
City, State: CI yyk M IQ ton rj( O C),-I
Phone: Q 3 ` 5A`1 - V (-1 q
Property Owner
Name: mocks Vh I f
Address: a(..)3 S,\4 1 V C-11�-tr- Ed
City, State: ;�l)1 cn C e , MA
I, Ran J f f oy-d S (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date l D la (0 J'
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-
203 Sylvester Road Florence, MA 01062
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 10/26/15
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:
Address of Work: 203 Sylvester Road Florence, MA 01062
Owners Name: Thomas Schiff
Date of Permit/Application: 10/26/15
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: "--ig
I hereby apply for a permit as the agent of the owner:
Date: 10/26/15 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.# :
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction SupeiZi Or
License: CS-074539
SEAN R JEFFORI,* -
13 TERRACE VIEW
EASTILkWTONN[At
Expiration
Commissioner 11/28/2016
dX/ e (Pow"noon-"Awl h' a 0*/-�ac��
_ 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 F Renewal r 1 Employment (_ Lost Card
SCA 1 0 20M-05/11
Affairs&rBu yes.Regulation License or registration valid for individul use only
Office of Consumer Affairs&Bus es'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
SEANJEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW g � .
EASTHAMPTON,MA 01027 Undersecreta—
ry Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
M Office of Investigations
i a 1 Congress Street,Suite 100
` Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
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. ❑ 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, ❑Demolition
working or me in an capacity. employees and have workers'
g Y P tY• 9. ❑Building addition
[No workers' comp.insurance comp.insurance.t
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 11.❑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' 13.0 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 anew 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.
T 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 21,301(0
Job Site Address: 203 Sylvester Rd 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 and penalties er' at the information provided above is true and correct
Signature: Date: 10/26/15
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):
I.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 1 $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 up to 35,000 cu.f
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
413-529-0544 seen @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 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
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 wide 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
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.
SEE ATTACHED SIGNATURE AUTHORIZATION FORM 10-26-15
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 be y edge and understanding.
SEAN R JEFFORDS 10/26/15
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTE
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/dps
2. When substantial work is plarmed,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"
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts State Building Code,780 CMR
USE
Building of M� 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
03 Sylvester Road Florence, MA 01062
1.1 a 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: Florence, MA 01062
Thomas Schiff _ _ _
Name(Print) City,State,ZIP
203 Sylvester Rd 413-727-3635
No.and Street Y Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other 1X Specify:Weatherization
Brief Description of Proposed Work':IMPROVF ATTIC INS[11 ATION TO C. DE ANn AIR RFAI INr
MEASURES _-- --
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itam Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ 6 S Indicate how fee is determined:
2.Electrical $ 119 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
Suppression)
Check No, eck Amount: Cash Amount:
6.Total Project Cost: $ 1000 13 Paid in F ❑Outstanding Balance Due: _
File#BP-2016-0615
APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 O
PROPERTY LOCATION 203 SYLVESTER RD
MAP 28 PARCEL 018 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT e
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
INFORMATION PRESENTED:
proved 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 y
Sign o Bui ing Of 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.
203 SYLVESTER RD BP-2016-0615
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:28-018 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-2016-0615
Project# JS-2016-001032
Est. Cost: $1000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq.ft.): Owner: SCHIFF THOMAS
Zoning: Applicant. BEYOND GREEN CONSTRUCTION
AT. 203 SYLVESTER RD
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTON MAO 1027 ISSUED ON.1114/2015 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 Signature:
FeeType: Date Paid: Amount:
Building 11/4/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner