23C-059 (3) 181 WILLOW ST BP-2016-1217
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C -059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-1217
Project# JS-2016-002096
Est. Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq. ft.): Owner: SILVA ROBIN B TRUSTEE
Zoning: URA(103)/WSP(101)/WP(25)/SR(0) Applicant: BEYOND GREEN CONSTRUCTION
AT: 181 WILLOW ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTON MA01 027 ISSUED ON:4/21/2016 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 4/21/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1217
APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 O
PROPERTY LOCATION 181 WILLOW ST
MAP 23C PARCEL 059 001 ZONE URA(103)/WSP(101)/WP(25)/SR(0)/
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
INFORMATION 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
em 't' Delay
Si re of Building 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.
� r
The Commonwealth of Massachusetts
L s Board of Building Regulations and Standards FOR
p_� o MUNICIPALITY
Massachusetts State Building Code,780 CMR USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Ntar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
F3uilding Official(Print Name) Signature Date
SECTION 1:SITE:INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
181 Willow St Florence. MA 01062
I.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)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private[I Zone: Outside Flood Zone? Municipal❑
Check if yes❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner]of Record:
Robin Silva Florence, MA 01062
Name(Print) City,State,ZIP
181 Willow Street 413-586-1436
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units Other CX Specify:Weatherization
Brief Description of Proposed Workz:IMPROVF ATTIC INSI II ATInN T()R-.IR AND AIR SFAI INC —
M ASURFS _--- —_--
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$__JqS Indicate how fee is determined:
13 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:__
5.Mechanical (Fire $ - - ------- �—
Suppression) Total All Fees:$ L75
ra / Check N eck Amount: Cash Amount:
6.Total Project Cost: $ ® �VU 0 Paid in 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-074539 XD0@M 11/28/2016
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 011)27 U Unrestricted(Buildings up to 35,000 cu.ft.
___ __-______..___ R Restricted 1&2 FamilyDwelling
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 -- —
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
13 Terrace View sean@beyondgreen.biz
No.and Street — Email address
Easthampton, M_A 010_27 413-529-0544
Ci /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..........EXX No...........❑
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 4/15/16
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the of owledge and understanding.
SEAN R JEFFORDS 4/15/16
Print Owner's or Authorized Agent's Name(Electronic Signatu Date
N TES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registcrcd 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/oca Information on the Construction Supervisor License can be found at www.mass.ro€ v/dns
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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathroomsNumber 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
- Department of Industrial Accidents
--!
Office of Investigations
- I Congress Street,Suite 100
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 1 am a employer with 3 _ 4. r_1I 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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 Buildingaddition
[No workers' comp. insurance comp. insurance.t ❑
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
q 1
3.❑ 1 am a homeowner doing all work officers have exercised their l I.❑Plumbing repairs or additions
myself. ' right of exemption per MGL
Y [No workerscomp. 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#I must also fill out the section below showing their workers'compensation policy information.
}f lomeowners who submit this aftidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
4Contractors 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.
/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, ` O(,()
Job Site Address: 181 Willow Street City/State/Zip: Florence, MAO 1062
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.
Tdo hereby certify under the pains and penalti f J that the information provided above is true and correct.
Si mature: Date: 4/15/16
Phone#: 413-5290544
Official use only. Do not write in this area,to be completed by city or townofficial.
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#:
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
t_'41"trUctiurl SUIjt:F%j""'r
License; CS-074539
SEAN R JEFFO"
13 TERRACE VDKW
EASTHAMPTOrf MA
t
si-t'—& . expiration
Commissioner 11128/9016
��Xel-
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' 0 20M-05/11
TleC
Office of Consumer Affairs&Bus
ifiess Regulation License or registration valid for individui use only
OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
egistration: 131279 Type: Office of Consumer Affairs and Business Regulation
r `?Expiration: 6!2912016 Individual
10 Park Plaza-Suite 5170
Boston,MA 02116
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW � 1
EASTHAMPTON,MA 01027 Undersecretary Not valid without signature
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggtsied Affidavit For Horne 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: 181 Willow St Florence, MA 01062
Owners Name: Robin Silva
Date of Permit/Application: 4/15/16
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: 4115116 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. #
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-
181 Willow St Florence, MA 01062
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE 4/15/16
�- City of Northampton
MassachusettsWZ
1� DEPARTMENT OF BUILDING INSPECTIONS s
212 Main Street • Municipal Building Jas DOD
Northampton, MA 01060 f6W y7�^
Property Address: 11 1 ow S+, 4—`'0Y (f. m vl 61 0(o;o
Contractor
Name:
Address: 13 a, e V\0,)-)
City, State:
Phone: 3 "1 ' 015)LALA
Property Owner
Name: i
Address: 1 C ( S i
City, State: t" { 0{rj)C'e 1q (�,I (j`�c� c
I, Sean k.f+()c W (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