07-061 (6) 367 NORTH FARMS RD BP-2017-0197
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 07-061 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-2017-0197
Project# JS-2017-000330
Est. Cost: $2000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Lali BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq.ft.): 24567.84 Owner: WOODMAN MARILYN
Zoning: RR(I00)/WSP(100)/ Applicant: BEYOND GREEN CONSTRUCTION
AT: 367 NORTH FARMS RD
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 O WC
EASTHAMPTONMA01027 ISSUED ON:8/16/2016 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 8/16/2016 0:00:00 $72.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0197
APPLICANT/CONTACT PERSON BEYOND GREEN CONSTRUCTION
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON01027(413)529-0544 0
PROPERTY LOCATION 367 NORTH FARMS RD
MAP 07 PARCEL 061 001 ZONE RR(I00)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid �6
Building Permit Filled out
Fee Paid
TypeofConstruction: 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
INFOBNIATION PRESENTED:
i.Xpproved 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
Signare ilding Offic al 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.
fin- • Th Commonwealth of Massachusetts
''1/4".13 B rd 4f Building Regulations and Standards FOR
AUG ' 5 A716 / sa usetts State Building Code,780 CMR MUNICIPALITY
USE
Dario t: . • Permit •p• ication To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
noATMnmsrogiuo ;.'is One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
` r •& 7 ' M4
I.1a Is this an accepted street?yes no OI �a 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 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
MWA\Y kii°Como-v� -Roftncr )lAw C)( 0(-4/D-
Name(Pri Cit,State,ZIP
3(o] N lo-rens gat 413 - 5 (0- 75a3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other @ Specify:UJ eCtkPt(1ZQ.Tl Ur`
Brief Description of Proposed Work2: irfQ(Duf C\*i( 11)5(AACt.YIClf) N C 0.rd
akw, 5e(31 Mf(iSLu su_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I. Building Permit Fee:$ 7 a Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$ 7'3 ��}}�\ Check No.,, Check Amount 9^- Cash Amount:
6.Total Project Cost: $
00 00 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVIc. S
5.1 Construction Supervisor License(CSL) ' — `-4 539 I i/ / (42
SEAN R JEFFORDS
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
13 TERRACE VIEW
Type Description
No.and Street U Unrestricted(Buildings up to 35,000 cu.fi.)
EASTHAMPTON,MA 01027 R Restricted 1&2 Family Dwelling
Cityflown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413-529-0544 SF,ANQBEYONDGREEN.BIZ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) 3I &79 lag/j e
Sean R Jeffords-Beyond Green Construction HBC Registration Number Expiration Date
HIC Company Name or 111C Registrant Name
13 Terrace View sean@bevondereen 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 CONTRACTOR4ie" APPLIES FOR BUILDING PERMIT
F
I,as Owner of the subject property,hereby authorize lV1� �,(err ConsSerf u cktov
to act on my behalf,in all matters relative to work authorize by this building permit application.
see O dki\CknchkCjitio
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest nde e pains and penalties of perjury that all of the information
contained in this application is true and c the best of my knowledge and understanding.
_Sean Jeffords '?//a// Co
Print Owner's or Authorized Agent's Name(El ronic 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.2orbca 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"may be substituted for"Total Project Cost"
Lt.'s.. The Commonwealth of Massachusetts
1.
=-7.7-7.:7------t_f! Department ooflnnstrtatAccidents
-- Office f Investigations
E -H_
_ :W . 600 Washington Street
1 IT v" Boston,M.4 02111
'' www ntass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlambers
Applicant Information Please Print Legibly
Name(Basmess/OrgmdratioMndividuat): ckJ111'ilt-i, (-1_Y p r,`1 I fl n.Sil li .TIC 1
Addreso: 13 1 PX I C1( ( 'V.i e S ti?
. al
City/State/Zip: 1 -'111r: Cv DkC it r�r Phone#:_-_ L113 - - Cy_
G��{y
Are you an employer?Check the appropriate box: Type of project(required):
1.®.I am a employer with 3 4. ❑ I am a general contractor and I
have hired the sub-conhactois 6. 0 New constmetion
employees(gill and/or part-time).*
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0ldaildia8 addition
[No workers'comp insurance comp.imam&
required.] S. D We are a corporation and its 10.0 Electrical repairs or additions
3.❑ i am ahomeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MOL 12.❑Roof repass
insurance required]t c.152,§1(4),and we have no _
employees.[No workers' 13 f0ther kivi(.'ii.i'h .r‘ 7-r),„-Li. L c\
comp.insurance required.]
eAny npplicantthat checks box el must else tilt out the section below showing their weds&compeasoion policy irdbaoaiiot
r Humemvaem who submit this of rtdava Mowing they are doing all work and then Mantas eonnuctors mast submh a naw ffidavit indicating sack
to etaaors that check this boxmmtattached an addltiomt sheet showing the name of the subcontractors end gala whether ornetihasa ea0ttes have
employees,ifthe subcentmciom have employees.they:mgt provide their workers'comp.policy number.
_.”....
I am as employer that is providing workers'contpenaWion insurance for my employees Below is the policy and Job site
information.
Insurance Company Name: 1,O - _ /
t�liY l)t. %,i�7... �,. II`1J� i✓t {'IC ±
NI
Policy ii or Self-ins.Lie.#: .J W'C ( i ,C. 0 1 Expiration Date: I — I — / 7
Mb Site Address: 261 N -Prim c /Ca( City/State/Zip: -P/D/t'Orel It' 14- d 10(g D.-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties ofa
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 cerafy underthepains and perfnry that the information provided above it true and correct.
$ienature. Date: 4el4 a I I o
Phone If: Li I.j - 5-, `I ' CSL- (-I'
Official use only. Do notwrimtn this area,to be completed by tgy or town official
City or Town: Permit/Lieense#
Issuing Authority(circle one):
1.Board of Health 2.BuildingDepariment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone d:
ArkPermit Authorization �°" `°'�,
mass save Form PARMUNMNO
eggIRAMOR
3•Y•Yd•a4rr•^•T�denry
Site ID: S00002096500 Customer: MARILYN WOODMAN
I, MARILYN WOODMAN ,owner of the property located at:
(Ownet's Name,printed)
367 N Farms Rd FLORENCE
(Rroceity Street Address! (OMI
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.
Owner's Signature: /
Date: l
��d
er
000000000000000000000000000000000000000000000000000000c00000000000000
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
•
Participating Contractor Date
CLEAResult • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800480-7472 kat
For Office Use only
Rev.102015
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Somata!Affidavit Fa Hao[LmmnrfnitI Conuecb,remit Application
For Office Use Only
Permit No.:
Date: _......... _..
Note 142 A, requires that the Arecoostruction, alteration, renovation, repair, modernization, cooversinn,
improvement, removal or demolition or the constructional of an addition to any pre-existing owner occupied
budding 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.re���
Type of Work: Weatherization Est. Cost: ;Gap
_
Address of Work: (,6) ttJ -Va.1 M.�s/ 1 d ��1owwnC' M 14 OI CO(o
Owners Name: M (l,ff ISI V4 LQ O 0I�t,�r
Date of Permit/Application: ' I -a) I (p_
l 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. # :
- i
Massachusetts-Department of Public Safety
Soar°of Buud r.g Regularrons ana Staedares
License CS-074539
SEAN R JEFFOROS ,,ma�yy
13 TERRACE VRW 'sgc'
EASIHAMPTOPFMA. ;
.. _m,ratlot
Commissioner 11/28/2016
QAe t O4n/nvntuenidt ¢�C��GlclJfx,Cf2ule�r
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 131279
Type: Individual
Expiration: 6/29/2018 Tr# 288957
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW _ ---_-- -
EASTHAMPTON, MA 01027 - --------
Update Address and return card.Mark reason for change.
AddressRenewal - 'I Employment Lost Card
SCA1 0 20M-05(11 —.
/GYr pi not mrreda / 71. /u:..// -_. .._
�_ - Officeof Consumer Affairs Si Businessn Regulation tion Lice se or registration valid for individual use only the
:3 —�j,HOME IMPROVEMENT CONTRACTOR before expiration date. d return to:
Registration: 131279 Type: Office of Consumer Affairs and and Business Regulation
'�Expiration: 6/29/2018 Individual 10 Park Plaza-Suite 5170
Boston.MA 02116
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW ., _
EASTHAMPTON,MA 01027 Undersecretary 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
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-
3(0-) N -Fr'r,i-m s Rd P lOr ri ce.) n_
TO BE DISPOSED AND TRANSPORTED BY- 01 OSYa
BEYOND GREEN CONSTRUCTION or
ALTERNATIVE RECYCLING
SIGNATURE
DATE g I I a I L