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25C-014 (5) 90 WOODMONT RD BP-2016-1349 GIs#: COMMOl WEALTH OF MASSACHUSETTS Map:Block: 25C-014 ICITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate oa: INSULATION BUILDING PERMIT Permit# BP-2016-1349 Project# JS-2016-002315 Est. Cost: $4000.00 Fee: $85.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BEYOND GREEN CONSTRUCTION 074539 Lot Size(sq.ft.): 28793.16 Owner• JACKSON CAROLE A&LEON B JACKSON toning URB(100)/ Applicant: BEYOND GREEN CONSTRUCTION AT. 90 WOODMONT RD Applicant Address: Phone: Insurance: 13 TERRACE VIEW (413) 529-0544 O WC EASTHAMPTONMA01027 ISSUED ON.5/18/2016 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: Drivew4y Final: Final: Final• Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITE'' OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeeType: Date Paid: Amount: Building 5/18/2016 0:00:00 $85.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File# BP-2016-1349 APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 Q PROPERTY LOCATION 90 WOODMONT RD MAP 25C PARCEL 014 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATIOV CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Z7 777 on Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existiniz Accesso1y Structure Buildine Plans Included: Owner/Statement or License 074539 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 1R AT1 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 aDeit' D elayy / S-111,21-61 Sig ure of Ifui1&J'Oft7ciaf 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. REG' The qomi nonwealth o Massachusetts MAY ' Ullbard o Bui ing Regulations and Standards FOR Massach ett State Building Code, 780 CMR MUNICIPALITY iWECnOW USE 1u o 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: SITi INFORMATION I l Property Address: 1.2 Assessors Map&Parcel Numbers LI a Is this an accepted street?yes no Obo Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use t,ot Area(sq 11) 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❑ Ch!jck if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROP RTY OWNERSHIP' 2.1 Owner of Record: CCS rD I _)010-so AJD r Name(Print) C ty,State,ZIP 90 hJr�l� oat 9d No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other h Specify:1;Q(,�k-Vt f r, 2 GL-1-i,pry Brief Description of Proposed Work2: 1 (��� i L 1 �� i ICL t n(� 1� ( (�CkQ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee:$ 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 $ Su ression) Total $ �/ /) Check o Check Amount: Cash Amount: 6. Total Project Cost: $ 1 O�V 0 Pail'in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C SEAN R JEFFORDS 5-3l ,/�0-FP o License Number Expiration Date Name of CSL Holder List CSL Type(see belWy) 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 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I ? i -7C9 -d9 - 1 d9 - I 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 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 .......... X 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 O Ocr e rv-) Cv()dfT U to act on my behalf,in all matters relative to work authorized y this building permit application. S'ff Ck_C S 1 ►I Print Owner's Name(ElectronicSignature) 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 ac rate the best of my knowledge and understanding. _Sean Jeffords S' 1 1 Print Owner's or Authorized Agent's Name(E tronic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass,govidps 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" Department use ony City of Northampton Status ofpemiit Building Department di i- Ctttrortveway Pei,rtii� rY 212 Main Street Selive Septic Availability Y '= Room 100 V�laterl�IVel1 Ava4latiiiijt Northampton, MA 01080 7v�o se�s iftSlructufal,l'(ans : phone 413-587-1240 Fax 413-587-1272 PiplSite Plaris_� ' ,° _ ` 4 } i ', Of11er Specify� - S APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office pt� Map: Lot Unit .Zone Overlay District im St.District CB District SECTION 2'-PROPERTY OWNERSHiP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: elephone Signa fe- 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3'=ESTIMATED CONSTRU CTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Oullding Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For O clal Use Only Building Permit Number. Dats Issued: Signature: Building Commissioner/Inspector of Buildings Date E i f The Commonweaft of Massachusetts Department of laolustrial Accidents Office of Investigations IF 600 Washii'tgton Street Boston,M4 02111 www.ma,#s gov/dia Workers' Compensation Insurance Aft>tidavW Builders/Contractors/Electricians/Plumbers Anulicant Information Please Print Legibly Name(Business/Organization/Individual): (7 fl t' f r ) C (1 Address: I l Ci /State/Zip: ^pI-A i hone#: LA t�- �J dGl -0`0 CA L Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b New construction 2.❑ 1 an a sole proprietor or partner- listed on tho attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. [] We are a corporation and its 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp. right of exelplption per MGL 12.[]Roof repairs insurance required.]f c. 152,§1(4),and we have no 13.®Other ln1 eGl�l'1 employees.(No workers' �GL"to comp.ins ce required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowner:who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 wotirers'comp.policy number. I am an employer that is providing workers'compensation lnsrtrance for my employees. Below is thepollcy and Job site information. n ' insurance Company Name: Policy#or Self-ins.Lic.#: S C �000 C—) I Expiration Date: Job Site Address: !l a)J[mod-f RC's City/StatotZim. A)O r��a0�]Z�t1 �i 1/-\ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). cm3 ",D Failure to secure coverage as required under Section 25A of MQL 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. Ido hereby cerdfy under the pains and pe lti perjury that t the information provided above is true and corrects e: a Official use only. Do not write in this area,to be completed;by city or town off leFal City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Klerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: — City of Northampton • SS`s ��.s,�f Massachusetts DEPARTMENT OF BUDDING INSPECTIONS y° 212 Main Street • Municipal Building \ Northampton, MA 01060 Property Address: C� L� Wo'Y—' rY)O(I -" k)cJ !yO( Contractor Name: VeunnrA Arei,--nn tT Address: �_ f'rrare y City, State: Ea S`-1 Q00 (\ Vq U►0a1 Phone: `4 12---)— `Jaa' 0 5 L LI Property Owner Name: CarL CICl�U'n Address: 4C) WOUCLM—u/1 f V—d City, State: I`V rel CcXO D�Z:`rl { t rjy ( U Cc an �){���(� (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 J/ h h o J AFFIl)AVIT Home Improvem nt 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 constructi nal 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 contractor,with certain exceptions,along with other requirements. Type of Work: Weatherization Est. Cost: 000 Address of Work: u)(ba—mo, 14 Rte©r-� ft o t )(_0 Owners Name: C 0 1 i 0 (� YZ Soy-\ Date of Permit/Application: S, 1 ( � I T 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: 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. # : ` 1 Massachusetts -Department of Public Safety Board of Building regulations and Standards rori�;tructfgai superlINI,r -<cense: CS-074539 SEAN R JEFFORI?S 13 TERRACE VIEW EASTHAMPTON MA r W7r Expiration Commissioner 11/28/2016 R. -- i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 51.70 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 ( j Employment Lost Card SCA fia 20M-05/11 0 Office of Consumer Affairs&Busi4ss Regulation License or registration valid for individul use only g OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 1 egistration: 131279 Type: Office of Consumer Affairs and Business Regulation iration: 6/29/2016 Individual 10 Park Plaza-Suite 5170 x p Boston,MA 02116 SEAN JEFFORDS SEAN JEFFORDS 13 TERRACE VIEW EASTHAMPTON,MA 01027Un -- --- _- — dersecretary Not valid without signature BEYOND GREEN CONSTRUCTION DEBRIS DISPOSAL AFFIDAVIT IN ACCORDANCE WITH THE COMMONWEALTH OF MASSACHUSETTS DEBRIS DISPOSAL PROVISIONS OF MASSACHUSETTS GENERAL LAW CHAPTER 40, SECTION 5411 A CONDITION OF BUILDING PERMIT NUMBER FOR DEMOLITION WORK IS THAT THE DEBRIS RESULTING FROM THIS WORK $HALL 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 qO wowrnon± ed TO BE DISPOSED AND TRANSPORTED BY- BEYOND GREEN CONSTRUCTIION or ALTERNATIVE RECYCLING SIGNATURE DATE