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38A-004 RIGHT OF CANCELLATION CANCELLATION RIGHTS: The Homeowner is hereby notified that: YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY HERETO AT A PLACE OTHER THAN AT AN ADDRESS OF THE SELLER (CONTRACTOR) WHICH MAY BE THE SELLER'S MAIN OFFICE OR BRANCH THEREOF, PROVIDED YOU NOTIFY THE SELLER IN WRITING AT IT'S MAIN OFFICE OR BRANCH BY ORDINARY MAIL, POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. EXHIBIT A NOTICE TO PROCEED Owner hereby requests that Contractor commence construction of the WORK as defined in the Contract between Owner and Contractor dated November 11. 2009 (the "Contract "). Pursuant to the provisions of Section 3.1 of the Contract, Contractor shall commence construction on or before November 16, 2009 fill in date (5) days from date of Notice to Proceed (the Commencement Date) The WORK shall be completed by Contractor on or before November 28 , 2009 fill in date which is (12) days from Commencement Date The Commencement Date and Date of Completion stated in this Notice to Proceed shall be incorporated by reference into the Contract. Owner(s) r ? AGREED TO; Contra f� " dent CHAGNON :UILDING & REMODELING Inc Dated: f/ , 2009 Contractor Initial • 1-i' Owners Initials: /W Page 9 of 12 Copyright © 2009 Chagnon Building & Remodeling LLC Created on 11/10/2009 2:38:00 PM Woodfin Siding and Roofing CONTRACT 111109 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 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 Hour), 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 - cenjunction,.to the_building permitissued,_ 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 1 , 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 _ 1.= Office of Investigations =� 600 Washington Street �� Boston, M4 02111 „� . www /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly w/ n Name ( Business /Organization/Individual): L h ` f ett.� 3 ',�- I>, fti I r A/Yof,e ,.-y Address: l 5 )G4�Yt ,1 l Cit /State/Zip: l�lG3� Phone # : /3 _�l.'? z Are you an employer? Check the appropriate box: Type of project (required): / 1. [21-hrm a employer er with ) 4._ fl I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub - contractors listed on the attached sheet. 7. 0 2. Q I am a sole proprietor or partner- Remodeling ship and have. no P' loyees These sub - contractors have. $. 0 Dernoliuon in an capacity. employees and have workers' working for me Y P ty. 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am- a-homeo-w$er -d ing-all- woric Alfa= havexeezcise&their___ __1..1 -- P-.lumbingrepairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited. ] . `Any applicant that checks box #I -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 .arrarhed an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. lithe 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 f ormation mp Y l�'1 ! 1 ' Insurance Co an Name: � �,Z r , 61-5/44-4-/-- 7 Policy # or Self-ins. Lic. #: / Expiration Date: Job Site Address: d got t5 A ) r City /State/Zip: / `C , lf 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 $1500.00 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. Ile advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification 1 do_hereby certify under the pains and penalties of perjury that the information provided above rue_andicorrect. __.: Signature: Date: rtf Phone #: Official use only. D� no write be completed by city or town offutaL City or Town: Permit/License # Issuing Authority (circle ®ne): I. 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 Applicable ❑ Name of License Holder : 61/�q V C %i dt_ - 60175 01 7 5 // ` License Number q, s/ /3ri el y . r A- i dl/ ,,14,9 0055 9/..30/60 /r Address / Expiration Date Si nature Telephone 9, Registered.Home lmprovementContractor :;' Not Applicable ❑ J h / .. .. t:�i] / ✓fit . drvf�:Il� fr A,440'0�'li`. -Z,r /1(275 7 Company Naniq Registration Number 6 Ck, / / M oe35" Q /9, /aaif Address �] Expirati n Date Telephone 4/ 3'0 -54 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25((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 No ❑ The_current-exemption for "homeowners" was extended to include Owner 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. Alco be adviced that .rith referent-eh fhapt w 157 (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) youliire - 6 perform work for this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of o amp on •r•nances, a Y -- tts-General- Laws - Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing FZ9 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [IZI] Decks [Q Siding [Ii] Other [EX Brief D e s c r i p t i o n of Pro o d p� / �y Work: ravC0 p l r�cG4v e RP si PS� 5(>4 I I ���¢t�L g f i,�' Alteration of existing bedroom Yes b No Adding new bedroom Yes �✓ No , Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If .New house and`or.add'ition #o'existincybousinq; complete -the fcilloWinq: a. Use of building : One Family v Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? P lj d. Proposed Square footage of new construction. Dimensions e. Number of stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 5ee b' y Le , as Owner of the subject property ` hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 6 1-Ai c4 , as Owner /Authorized Agent hereby de are that the stateme_n s 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 /0 tI Signa ure of Own. r /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L. ,. _m._ _ R:. L.' _ ..__. R. Rear Building Height Bldg. Square Footage ° ___ % Open Space Footage ° /o (Lot area minus bldg & paved �. parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW Or YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Cr YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 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 Gr IF YES, describe size, type and location: - D. - Are any proposed changes to or additions of signs info ed' for the property ? YES 0 NO IF YES, describe size, type and location: 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. kY & Departmet Pnly �M1 A City of Northampton Status of Pertmtt x Building Department GurJ Cu Dn wa ercrtzt , 212 Main Street S4'1Nlrl /$e?IO;tty :Room 100 Noi mpton, MA 01060 Tcs �a€tna�>atPn phone 41-3- 587 -1240 Fax 413 -587 -1272 y $ Y M1J't �i P iY , ', Sqp ffi d f k w5 Y 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 j PAY {5 P.-1, Pe Map Lot Unit / 1 �`� � Oar j iMp v / M ,Q /r cla 6-0 Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: 3 - g3'— 970r Telephone Signature 2.2 Authorized Agent: i / y CI Name (Prin Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION! COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building L olt CC' (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total: Check Number This SQCt nn Fnr tIfficial _ iJSP C)niy Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2010 -0525 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0525 Proiect # JS- 2010- 000739 Est. Cost: $6500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GARY J CHAGNON 060175 Lot Size(sq. ft.): 11412.72 Owner: PUSHKIN MICHAEL A LIVING TRUST Zoninm: URB(100)/ Applicant: GARY J CHAGNON AT: 2 BURTS PIT RD Applicant Address: Phone: Insurance: 91 STOCKBRIDGE ST (413) 259 -6785 WC HADLEYMA01035 ISSUED ON:11/13/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE ROT,STRIP & SHIGNLE ROOF & INSTALL SIDING 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 11/13/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo