25A-163 (2) 239 NORTH ST BP-2016-1305
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 163 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-2016-1305
Project# JS-2016-002247
Est. Cost: $3000.00
Fee: $78.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq. ft.): 13416.48 Owner: LITWILLER LAURA
Zoning: URB(100)/ Applicant: BEYOND GREEN CONSTRUCTION
AT. 239 NORTH ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 WC
EASTHAMPTONMA01027 ISSUED ON.5/10/2016 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 Sienature:
FeeType: Date Paid: Amount:
Building 5/10/2016 0:00:00 $78.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1305
APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 Q
PROPERTY LOCATION 239 NORTH ST
MAP 25A PARCEL 163 001 ZONE URB(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 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:
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
oli i la
Si uildi g O ficia 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.
43 ' he ommonwealth of Massachusetts
of uilding Regulations and Standards FOR
✓" s etts State Building Code, 780 CMR MUNICIPALITY
of°'': �TO� N USE
ng 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: SIT INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
a3q r\)0q" 'Silca IJOrW(kWVAV\,t,�.A-
L l a Is this an accepted street?yes no 0\0(0� 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:
Zone: Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ww,q. U+tAid Ie r _(U(�C 4-(nU m fl N�w1 010(t)(D
Name(Print) City,State,ZIP
a39 rVOr+4, Si-r-(cf ajU4-LAaa-25�3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other
Brief Description of Proposed Work 2: �M C M\K 6ji'I C `nS(A 1 CL b1`-\ t) CC](:A_E
06117 123A MCOLSwf le-5 -
SECTION 4: ESTIMATEDCONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials).
1. Building $ 1. Building Permit Fee:$ 1 T Indicate how fee is determined:
2. Electrical $ ❑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 $
Suppression) Total All �Fu es:$
Check No Check Amount: Cash Amount:
6.Total Project Cost: $ �(��� ❑paid in 1 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
SEAN R JEFFORDS CS-074539 Von Idol(G
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
13 TERRACE VIEW
Type Description
No.and Street U Unrestricted(Buildings up to 35,000 cu.ft.)
EASTHAMPTON.MA 01027
R Restricted 1&2 Family Dwelling
M Mason
City/Town,State,ZIP
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413-529-0544 SEANkBEYONDGREEN.BIZ I j Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 131279 o't OL
Sean R Jeffords-Beyond Green Construction HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
13 Terrace View seanbe and reen.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 ..........X No...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOUR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 4—I L�rld �j.wl1 Cc ng—rciohb n
to act on my behalf, in all matters relative to work authorized`t�y this building permit application.
See a 41-W-Wo 5%a /
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:a re best of my knowledge and understanding.
_Sean Jeffords /J / 1 ('0
Print Owner's or Authorized Agent's Name(Electifnic 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 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.govioca Information on the Construction Supervisor License can be found at www.mass.Qov/ap
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,DIA 02111
www.num gov/dia
Workers' Compensation Insurance Affidavit: Builders/ContmetorsAElectrieians/Plumbers
Apulicant Information Please Print Legibly
Name(Business/Organization/Individual): WA T C1 r�. V� CCn2, 1 1_l i ( 1n
�
Address:
City/State/Zip: L Q Sji2C� 'Phone#: y
Are you an employer?Check the appropriate box: Type of project(required):
1.M-1 am a employer with 3 4. ❑ I am a general conitactor and I 6 Q New construction
employees(full and/or part-time)." have hired the sub-contractors
2.[J 1 am a sole proprietor or partner- listed on the attached sheet. ?. ❑Remodeling
ship and have no employees These sub-contractors have g, [l Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insuronce.t g• ❑Building addition
required.] S. (] We are a corporation and its 10.[]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 L[]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 13.E4 Other (,t1PGi�1��'�� Zc c+�01employees.[No workers'
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 now affidavit indicating such.
tContractors 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. iiSu
Insurance Company Name: Ub rG uwrd 4(- 5canoe
Policy#or Self-ins.Lic.#: Sly CC 7 0(3 Expiration Date:
Job Site Address: ��� N n l <S��i° (� City/State/Zip:, choa�m tyn M.6 al 0 Co 0
'T
Attach a copy of the workers'compensation pulley 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 pe erjury that the information provided above is true and correct.
e:
Dale,
Phone#:--H! q
Official use only. Do not write in this area,to be completed by city or town ofltelal
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
AW \
BEYOND GREEN
CONSTRUCTION
DEBRIS DISPOSAL AFFIDAVIT
IN ACCORDANCE WITH THE COMMONWEALTH OF
MASSACHUSETTS DEBRIS DISPOSAL PROVISIONS OF
MASSACHUSETTS GENERAL LAW CHAPTER 40, SECTION
541 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-
19 39 AUC)r4n (S+. uoL-d oto ,M r4 oaoc)
TO BE DISPOSED AND TRANSPORTED BY-
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE _1
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggestod 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: W QCU kbef Z OA� LY-) Est. Cost: n r)
Address of Work: 3 '99 N U r4" 3+ 0 0 N Ck rn o ton'�-k A b l u(0c)
Owners Name:LC.UCC Ck, C •f W1 J I U
Date of Permit/Application: -j—o— 1 -'o
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: J�'a' �� 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. # :
--- City of Northampton
��, ;. • S`s . : sic,
Massachusetts
f " f DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 �SNW 3'X111
Property Address: J39 wori4i (j,t &)D f inc YYIo�w,m GCS- o(Occo
Contractor
Name: ref DLTUCAJ Or-,
Address:
--LZ rra& V 1 f -)
City, State:
Phone: 5aC(- Q 5yY
Property Owner
Name: l_Cu"a L i +J I I I C4
Address: 029 CV orM--) j fr(c°
City, State: JU U ('41')C - n U d
T
1, Se ao 3P j�r(i (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
RISEa
�'_ 60 Shawmut[toad,Unit 2 1 Canton,MA 020211339-502-6335
ENGINEERING www.PJSEengineering.com
OWNER AUTHORIZATION FORM
{Owner's Name}
owner of the property located at:
(Properly Address)
�bkLA&�
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain 9,building
permit and to perform work on my property.This form is only valid with a signed contract.
nee Signator
Date
APR 2 2 2016