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23A-294 (2) THE FOLLOWING NOTICE OF CANCELLATION MUST BE IN DUPLICA'T'E, ATTACHED TO THE CONTRACT, FOR ANY SALE OVER 525 THAT TAKES PLACE AT THE CONSUMER'S HOME OR SOMEWHERE OTHER THAN THE BUSINESS LOCATION. THE WORDING IS SPECIFIED IN MGL C. 93 Section 48. A SIMILAR CANCELLATION NOTICE IS IS REQUIRED IF THE CONSUMER'S HOME IS BEING USED AS SECURITY IN THE CONTRACT. SEE CHAPTER 140D SECTION 10 THE NOTICE MUS I BE IN TEN POINT BOLD FACE TYPE - f NOTICE OF CANCELLATION date of transaction a You may cancel this transaction, without any penalty or obligation, within three days of the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does - not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without further obligation. If you fail to make the goods availableto the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to (name of seller) at (address of seller's place of business) not later than midnight of (date). I hereby cancel this transaction (date) buyer's signature "b. PAGE THREE CANCELLATION RIGHT You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller, which may be his main office or a branch thereof, provided that you notify the seller in writing at his main office or branch thereof by ordinary mail posted, by telegram or delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIG THIS CONTRA F THERE ARE ANY BLANK SPACES. Homeowner(s) Contracto NOTE IN ADDITION TO THE HOMEOWNER'S RIGHTS BY THE LAW, THE CONTRACTOR CAN REQUEST ARBITRATION TO RESOLVE DISPUTESWITH THE HOMEOWNER IF THAT IS AGREED TO BY BOTH PARTIES IN THE CONTRACT. IF THE CONTRACTOR APPLIES FOR ARBITRATION, THE HOMEOWNER MUST DELAY ANY COURT ACTION UNTIL AFTER THE ARBITRATION HEARING. OPTIONAL CONTRACTOR ARBITRATION AGREEMENT The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as approved in MGL C.142A. Contractor .A 4.. Homeowner G����% -fir Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute settlement initiated by the contractor. The owner may initiate alternative dispute resolution when this section is not signed by the parties. THIS IS A SAMPLE THAT, TO THE BEST OF OUR COLLECTIVE ABILITIES, CONTAINS ALL OF THE REQUIRED PIECES OF INFORMATION TO PRO ILET YOU AND YOUR CUSTOMERS. IT IS STRONGLY ADVISED THAT YOU TAKE THIS TO YOUR ATTORNEY FOR ANY FINE TUNING. N. , PAGE TWO Materials Contractor Will Supply l�� 1 L'S Materials or Labor To Be Supplied By Homeowner(s) 0 0- Csr IF CONTRACTOR IS DOING WORK FOR WHICH CONSTRUCTION - RELATED PERMITS ARE REQUIRES THE CONTRACTOR MUST OBTAIN THOSE PERMITS FOR THE HOMEOWNER. HOMEOWNERS WHO OBTAIN THEIR OWN PERMITS FOR THAT WORK CANNOT MAKE CLAIMS TO THE GUARANTY FUN OR BE ABLE TO OBLIGE THE CONTRACTOR TO GO TO ARBITRATION. THE HOMEOWNER IS RESPONSIBLE FOR OBTAINING ANY SPECIAL PERMITS THAT MAY BE REQUIRED UNDER THE ZONING BY -LAWS, CONSERVATION COMMISSION ORDERS, ETC. Contractor will obtain the following permits: Building Demolition Plumbing Electrical Gas Other (Describe) Total on ract Price ( in dollars and written otk in words) Z 2 000 �' W & x ( 4 V p - 1.--L � -- .. Z . c Downpayment of 5 7 a".. a". � must be paid by this date I ,F > / / THE CONTRACTOR MAY NOT TAKE PAYMENT OF MORE THAN ONE - THIRD OF THE CONTRACT PRICE BEFORE THE WORK STARTS UNLESS A GREATER AMOUNT IS NEEDED FOR THE ACTUAL COST OF ANY SPECIAL ORDER OR CUSTOM MADE MATERIAL OR EQUIPMENT WHICH MUST BE PAID FOR IN ADVANCE. DO NOT PAY IN FULL UNTIL THE WORK IS COMPLETED AND INSPECTED Schedule of Remaining Payments: Amount _5v u 0 , 6 4' At What Point (0 041— c c i l ON .Sd ov , 617 M IOD of __;_(Q q , �-' S A y ()Ad Description of Any Warranties Contractor: �� c � �q 7C! Description Of Any Lien Or Security Interest In The Residence As Part Of This Contract: NOP4,4 HOME OWNERS WHO DEAL WITH REGISTERED CONTRACTORS FOR WORK COVERED BY THE HOMI IMPROVEMENT LAW, MGL C. 142A, HAVE THE RIGHT TO REQUEST ARBITRATION OR TO SUE TO RESOLVE DISPUTES WITH THOSE CONTRACTORS. THEY MAY ALSO MAKE CLAIMS TO THE CONTRACTOR GUARANTY FUND FOR ACTUAL LOSES UP TO $10,000 IF THEY ARE UNABLE TO COLLECT THOSE LOSES FROM THEIR CONTRACTORS. FOR INFORMATION ABOUT ARBITRATION AND THE GUARANTY FUND, CONTACT THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS (617) 727 -7780 r HOME IMPROVEMENT CONTRACT This is the complete agreement between the contractor and the homeowner made on this date O c- Z1 j Zo l Name of Contractor: C_ A !ZD l / PIN Address: 5 677 —h^- 7 �/ A % FI61_6' 11 , ® /03 f ( may not be a post office box) /-17//3--5/74— Z o Telephone Number: Name of Salesperson (if any) I 1 N AS OF JULY 1, 1992, ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS COVERED BY MGL CHAPTER 142A MUST BE REGISTERED WITH THE STATE TO CHECK ON A REGISTRATION CONTACT THE DIRECTOR, HOME IMPROVEMENT CONTRACTOR REGISTRATION, ONE ASHBURTON PLACE , ROOM 1301, BOSTON, MA 02108, (617) 727 -8598. Contractor's Registration Number _4 2 , 4 + / /3 (, 7Z / , 1 , G HOMEOWNERS WHO DEAL WITH UNREGI E REIYC O NTRACTORS CANNO74LI E THEM TO GO TO ARBITRATION AND CANNOT MAKE CLAIMS TO THE GUARANTY FUND UNDER THE HOME IMPROVEMENT LAW. Name(s) of Homeowner(s) 6 P1.a< 13A?LA (- - J l`` 6-og CI—/ Address Z mv.0 `' &,/! F LoII c �� ` WA 0/0 6 Z. Home Telephone: _-5 6 - 2Z6 7 Work Telephone: M /A- Date Work Will Begin: Oc 3 / 1/ Date Work Will Be Substantially Completed: rvo VV 3 0 Zo / z These dates may change because of delays in getting materials, permits, inspections, weather conditions, subcontractors' schedules or other problems beyond the subcontractor's control. The contractor agrees to let the homeowner know about any delays immediately. Changes to dates, the work to be done, materials or price will be written and then initialed by the contractor and the homeowner(s), and attached to this contract. Description of Work by Contractor: (et.`- M b FILL (o o FS 0 N O 1-0,4 6- 14- d o .1 ' ?9T ' 6 ° Y&Y , 04192IJ C C J: L . / 0 dr' Vwi d — d 7 dl/N / _ . � • L 3Q / -- ' LV Root — L f L401v ��_' 2 ,c < f Jnl F k�� S Rif M o U --� 2 A- ' Gam% LA C- r C f -- hn 6--F [ / - 4 City of Northampton Massachusetts ' Wi , . r j "17 DEPARTMENT OF BUILDING INSPECTIONS r _; 212 Main Street • Municipal Building ' a' Northampton, MA 01060 Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and /or farm structures. A person who constructs more than one home in a two - year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..,= 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): (N Address: 4 f'- 3 —J' S� J •=1 F /c:2-. 0l 3W City /State /Zip: Phone #: 1 /`�.� ._ +$— 6.� Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ['New construction I am a sole proprietor or partner- ors listed on the attached sheet. 7. ❑Remodeling These sub-contractors have ship and have no employees 8. ❑ 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 10.0 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 exemption per MGL 12oof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other 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 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. Insurance Company Name: -� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 2 4_4 / City /State /Zip: Q Cor 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. I do hereby certify er pains p allies of perjury that the information provided above is tr e and cor ct. -- Signature: Date: /6 c,( _ p /� ff Phone #: / ' (� � Y a ' [� 2-10 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: � Not Appl ❑ Name of License Holder : ( ) `�-_1 ✓ p 1 - l 2 £ F' / iI 14 License Number pvt Address Expiration Date �f 74 -. rF /�2 D �� . O /o 9 Signature elephone 7/ 2d/2. 9:.. e • istered, kliome in • rovement Coritractor." : , ' l n; Not Applicable ❑ Company Na Registra � ( 2 �� on Nu1nb�� 9 L Address xpiration Dat Y � ` 6 elephone 43 7 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c. 152, § 25C(6j) 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 ❑ No ❑ a ®(�)C1 ° sn "fie a.e on The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside; ,on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5- 'DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ��4;! Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Ej Siding [D] Other [D] Brief Description of Prop se o fi , d r -1 D i p I E - 0 ( e '/ 8 V p L—i Work: .g T�i a .2 J !� Alteration of existing bedroom Yes __tc,.. No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if 1E �' douse #anci,or a iaition.to ex istinq...housiri csimpl'ete} he. * #ol.low nq: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: K/ Number of Bathrooms c. Is there a garage attached? N d. Proposed Square footage of new construction. © Dimensions e. Number of stories? f. Method of heating? O / _ Fireplaces or Woodstoves Number of each ' g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction ad0 M 6' i. Is construction within 100 ft. of wetlands? Yes x No. Is construction within 100 yr. floodplain Yes x No j. Depth of basement or cellar floor below finished grade ( G fi k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer K Private well City water Supply SECTION 7a OWNER AUTHORIZATION ,TO BECOMPLETED WHEN ' OWNERS AGENT OR APPLIES FOR BUILDING PE RMIT 1 13 A-R8 -•A P u (, 2Q T , as Owner of the subject property rt hereby authorize S C 0 ��Q"f L l to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name I 7 ,`/\ Owner/Agent Signature of Owner /Agent a 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by'2oning This column to be filled in by Building Department Lot Size / _ / O i 3 Frontage , Setbacks Front =/..-- j 1 f Side L:k-.F4 -= R: 1 L : I J l . 1 Rear = i i Building Height z a Bldg. Square Footage Open Space Footage , (Lot area minus bldg & paved i i parking) # of Parking Spaces Fill: _w ._ g (volume &Location) � � A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 I IF YES: enter Book Page; 1 and /or Document #1 1 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO . : IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e IF YES, describe size, type and location: I E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a;�Depa eat use an(Y �' • City of No rthampton S a ofPerm x f�} Bu Departme Cu � P rinit : � � �. 212 Main Street S ew e r • t c = a l bill '� -- - - , � y k Room 100 11 sr... e l 7 'fi . � ; • No rthampton, MA 01060 v• `- , :a f r u a � ' phone 413- 587 -1240 Fax 413 - 587 -1272 P t an ,t er 5 i ec( d�� ' APPLICATION TO CONSTRUCT, ALTER, RE PAIR , RENOVATE OR DEMO LISH A ONE O R TWO FAMILY DW E LL S E CT ION 1 SITE INFORMATION' ,' x This se °to be completed b y o ffic e : 1.1 Property Address: � ; x a x ., ii. a ' � ' € ^ � {��� s s� if h� � �.`S > �4 , ,.4 � ?:Z td ".tC"z dt# Y � ) 1 � > . Mtap a', ▪ Lo t ` � u .. ; . , Unit •1 . �' .,. *� - • ` y ▪ h ,,,,.q x -"D' a s �, s . . i i • c g5 4 Ld2�n D AGEN T 2.1 Owner of Record: Current Maili Name (Print) ng Address: �� Q 6L Telephone r ., Signature �� . 7 2.2 Autho I C t- r—�t —, p /1•1 N J 6 L m rized Agen �S�I Name (Print) z Signature TelephoneCurrent Mailing Address: SECT ION 3-z ESTIMATED C O N STRUCTI ON COSTS Item Estimated ) to be O Use C{n completed by Cost permit (Dollars applicant 1. Building 2 G (b (a) Building Perm Fee 2. Electrical ), Estimated Total Cost of Cons truction fro ( 6) 3. Plumbing Building Permit Fed 4. Mec hanical (HVAC) 5. Fire Protection 6. Tota (1 + +3 +4 +5) ZC) (>�� v N Check This Section'For Official Use Only - Buildin Perm Number D ate 9 Issue Sig nature. Buildin Commissioner /Insp of Buildings li Date , 25 LANDY AVE BP- 2012 -0435 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 294 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -0435 Project # JS- 2012- 000694 Est. Cost: $20000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD FINN 050848 Lot Size(sq. ft.): 20473.20 Owner: YUSCAVAGE JOHN M & BARBARA A FUNGAROLI Zoning: URB(100)/ Applicant: RICHARD FINN AT: 25 LANDY AVE Applicant Address: Phone: Insurance: 43 ELM ST (413) 548 -6240 0 HATFI ELDMA01038 ISSUED ON:10/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 10/27/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner