17A-067 (6) 22 MOUNTAIN ST BP-2020-1023
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mo.-Block: 17A-067 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-2020-1023
Project# JS-2020-001726
Est.Cost: $5000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: BEYOND GREEN CONSTRUCTION 074539
Lot Size(sq. ft.): 22999.68 Owner: CORWIN JULIE
Zoning: RI(100)/URA(100)/WSP(l00)/ Applicant. BEYOND GREEN CONSTRUCTION
AT. 22 MOUNTAIN ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (413) 529-0544 WC
EASTHAMPTONMA01027 ISSUED ON:3/13/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEAL & INSULATE ATTIC & KNEE WALL
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 3/13/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
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 Applie
6AL �I 3 ; -20
Building Official(Print Name) Signature to
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 MAssessors ap&Parcel Numbers n
.z o„h4401062-o SI- F�ercaLIMA D106
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: V � �� 1.4 Property Dimensions:
Zoning District Proposed Ise 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 OWNERSHIPI
2.1 Owned of Record:
'),,, z Co s.,., V,, �t o,-f Kc L M A o k o 2.,
Name(Print) City,State,ZIP
'ZZ ✓V107g( Li25 922-7 ) ccrw;h b 'S7/0 ti. l . co�.
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-0Occupied ❑ Repairs(s) ❑ Alteration(s) 13Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other, 9T Specify: -c-, ecL a 4,.o
Brief Description of Proposed Work': (:I,,r 1 4 s a` I, t` (�tj ,4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $_JJ 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:
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� ❑paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
J lina N K `, -e��7 rJ S License Number Expiration Date
Name of CSL Holder
T ` � List CSL Type(see below)
t !2 2 1 -<rracc V < <-w
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
Cas exyl-A oyv /V /t n 1 0 Z-7 R Restricted 1&2 Family Dwelling
City/Town,State,WP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4111 1; Z�-1 05 q J 5 e CA N. bey o f of Cf-c„, L I I Insulation
Telephone o Email addres:i- D Demolition
5.2 Registered Home Improovement Contractor(HIC) 1 1 7 �J 6 S lq /zal0
SICCA-1 ,�c �� 5 l�c.,v Kc� �r L v. �'�^5 a 'o v� HIC Registration Number Expiration Date
HIC Company Name or HIC Registr t Name yAA
1< fr,Cu V ^tw s�o, h rJ�yOKcCa(YGI 61 Z
No.and Street
w�0!rte l✓l 4 O t Oz- 7 6� ) � I,-L dj``1' Email ad ess
Ci /Town, State,ZIP Telephone
l
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 .......... d 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 ,°V M J 0>(Iec�- �-n n 5 4v J"o\111-
to act on my behalf,in all matters relative to work authorize by this building permit application.
lel Z/ Z.V l Zo L o
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby ttest under the pains and penalties of perjury that all of the information
contained in this application is tru accurate to the best of my knowledge and understanding.
ZZ� / Zoz0
Print Owner's or Authorized Ag e(Electronic 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.gov/dps
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"
i
i
Commonwealth of Massachusetts
` Division of Professional Licensure
i Board of Building Regulations and Standards
Constrq&jon Supervisor
CS-074539 E��ires: 11/28/2020
SEAN R JEFFORDS r.
i
13 TERRACE VIEW
EASTHAMPTON MA 01027
Commissioner
t
Office of Consumer Affairs andBusinessRegulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home improvement Contractor Registrabor
Type: Corporation
Registration: 191746
BEYOND GREEN CONSTRUCTION INC. Expiration: 05109!2020
13 TERRACE VIE'JV
EASTHAMPTON,MA 01027
Update Addreaa and noturn CaM.
205405!17
"11:.:` r�Nmr•Nrnrn�f���^lln rrrl�rr/!
office of Consumer Affairs&Business Regulation Registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR 9
TYPE:Ca aoraticn before the expiration date. !f found return to:
Reoistr4on Expiration office of Consumer Affairs and Business Regulation
191745 05/0912020 One Ashburton Place-Suite 1301
BEYOND GREEN CONSTRUCTION INC. Boston,NIA 02108
SEAN JEFFORDS
13 TERRACE VIEW Not valid without signature
EASTHkAPTON,MA 01027 Undersecretary
AFF—MAV-11
HoSne Inm--rov meat contractor f.a=.
SupplenieI t to Permit Appticacics.
For O$m Use On-,
F t No.:
v i t W t42 A. ruqu rds tat tile A=:{'.ot18LT[lidf3t2, 3i'LC'c'.ZIQIIr ':na o 3�UP ;. +I1£rt�T,tZe+.Lf
m xvv t,removal or demo;it on or Lhe cojtstrucdonal of an addition repair,
Owner
er occupied
b'dtding c'y g at least one but no mant than Ebur dwelliu =
g unit,car:v structures vabich arc adjacent to such
;'eiiC#C i}ce or Duil(LIM v b-w i s i:Vii!r+L'trt7t.•T {i i CZPCi^a'C_*?T •Al
i��certain ixcepLianss alozigAith atitez tcauirments.
" pe of Work. Mica herization
__— Est.Cost:
Work�Z Z MoUh �irh _ 12���___✓ �..Q1 U ( ZZ
1,w-mem Name: ! t _. , rw,; _
Dale of Perini;i Ap.Dlication: 2 / Z r 20 Z- �� - --
?hereby 0z_t fy that:
is u0i M..q=*ed for the nl?awing reason(s):.
Woik exeluded by law
rizb under$500.00 �
EuMn.g-B&owner occupied }
i
G-xrLiEa-lilting Eur^?permiL i
t ttaer{specity3
Notice is li=by give that:
_ I
()WN-ERS PULLING HEIR OWN PERMIT OR Di A1.JNU WIT-4 UNpEGISTERED CONTRACTORS
FOR APPLICABLE HOMWE 1M_PROV,q.fNT`ATORK DO NOT HAVE.ACCESS TO TIS 's
ARBrIMUTION PROGRAM OR GUAR-AN-1Y WD UNDER MGL G. 142A_
I heirby apply for a permit as the agr a of tiae u ter: (�
Date: Z.IZgy_!i�0 Z 0 Contractoar: BEYOND GREEN CONSTRUCTION Reg.4: 13 '279
CSR: SEAM R JEF;_0RDS
'to=w=tt3s`�r Ing t e aFxrl c notice,I hereby y;or a p&mit as 1-e owner oftbe property.
Date: Tol.#:
BEYONDAdF
GREEN
C0NSTRLC
DEBRIS DISPOSAL AFFIDA'iiI'T
IN ACCORDANCE WITH T;-i=- COMMONWEALTH OF
MASSACHIUSETFS DEBRIS DISPOSAL PROV1STONS OF
MASSACHUSE I T S GENERAL LAW CHAP ER 40, SECTION
54, A C3ND SON OF BUILDING PEP-MIT %NUN BEr
FOR DEMOLITION WORK IS THAT THrr_- DEBRIS
RESULTING FROM THIS WORK SHALL 55 REMOVED FROM
SITE AND DISPOSED OF IN A PROPERLY I ICENSED SOLID
WASTE DISPOSAL FACILITY AS DEFINED BY NIGL C111,
Si50A.
FACILITY-
ALTERNATIVE ReCycLING, NORTHAMPTON, MA
"'STRU(--RQN SITE ADD RESS-
zZ 0ti0 ( Z
BE DISPOSED AND TRANSPORTED BY-
3E'l OND GREEN CONSTRUCTION or
ALTERNATIVE RECVCLING
SIGNATURE__ --Z
— -
DATE 6 Za_ � 7-
�� 7t)__
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
> I Congress Street,Suite 100
Boston,MA 02114-2017
r
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): ld.�4 0 VL C"6 G 1A 4'1'r9 to
Address: I -e r r,c-G V >✓
City/State/Zip: E r MA OioL7 Phone#: X 1 5 S 2_� d5 L1 y
Are you an emplover?Check the appropriate box: Type Of project(required):
1.1yl am a employer with employees(full and/or part-time).* 7. ❑New construction
2.O I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.(No workers'comp.insurance required.]
9. El Demolition
3.F-1i am a homeowner doing all work myself.[No workers'comp.insurance required.]
10 ❑Building addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I wilt
ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These subcontractors have employees and have workers'comp.insurance.t I 'Z<:P,{ 1
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Other W rG+t, r�
rp
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. A r/
Insurance Company Name: J \ o s v C,r tA st,r r-CA,0 G
Policy#or Self-ins.Lic.#: 5 \,/V Et, 7 00 D S I Expiration Date: t ► c Z L
Job Site Address: Z-Z NL D v 1 g 'ti City/State/Zip:Fl o r r„n c e MA O[o�,Z
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of V
tement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepa' Wallies of perjury that the information provided above is true and correct
Si nature: Date: / 2-
Phone#: L� 1 S Z"Q 0 rj-�-J C-(
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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
DocuSign Envelo e ID:E7422347-102A-4348-B5BF-84F86BCE6CFE
Permit Authorization
1'YMS SCIW Form
Site ID: 3939190 Customer: Julie Corwin
I, Julie Corwin , owner of the property located at:
(Owner's Name,printed)
22 Mountain St Northampton, MA 01062
(Property Street Address) (City)
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.
DocuSigned by:
Owner's Signat er�J« (baAlilnr
2ABB79B061D8460
Date: 2/21/2020 112.-01 PM EST
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only