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38B-259
_ • r - in ac,iidorciance 'vvit the provis;ons of Mi_ o L 4, anknowlerice, as a condition of the Budding perrnit, ail debris resuftino from construction Pc. governed by this Building Permit shall be disposed of \\) Y (NANIE. OF FACLITY I a properly fns-ad soiid waste facility as defined by rce C., Ill, PR:NT OR TYPE THE LOW! NG INFORMATION: fs o. (NA P.ERMT P CAN r) (TYPE O M4 TEE/AL TO SE r)ISPI) =7 : FL) OC - (PROPERTY ili)DRF-SS) L•d c.)7.q$:'.L1? Av-rn HO The Commonwealth of Massachusetts I Print Form 1 Department of Industrial Accidents �„ , a� — Office of Investigations e 1 Congress Street, Suite 100 Boston, MA 02114 -2017 wwx.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Barron & Jacobs Associates, Inc. Address: 70 Old South Street City /State /Zip: Northampton, MA 01060 Phone #: (413) 586 -8998 Are you an employer? Check the appropriate box: Type of project (required): 1. M. I am a employer with I 1 4. ❑ I am a general contractor and I employees (full and /or part-time).* have hired the sub - contractors 6. [1] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [I Remodeling ship and have no employees These sub - contractors have 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 10.1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. comp. [No workers' com right of exemption per MGL y t p 1 4 and we have no 12.0 Roof repairs insurance required.] c. 152, § ()' employees. [No workers' 13. N Other 5i t71 N G 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. Insurance Company Name: Webber & Grinnell Insurance Agency, Inc. Policy # or Self -ins. Lic. #: WMZ 8006365012012 Expiration Date: 03/1/2013 Job Site Address: 56 R0 .t-i. Ave . City /State /Zip: NDATHATgPTol4 ai=060 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 certi y under the pains and penalties o Perjury that the information provided above is true and correct. Signature:; Z 17. 1 Date: 2 - ' 12 - Phone #: (11 - &O - 66 7 7 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 #: SIGNATURES By signing below, you agree to items A, B and C. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. A. Alternative Dispute Settlement (Arbitration Clause): The Seller and the Buyer hereby mutually agree, in advance, that in the event of a dispute concerning this Agreement, the parties shall submit such dispute to a professional, state - approved arbitration service (cost, if any, to be paid by the submitter) prior to either party proceeding to legal action in the courts. B. By signing this agreement, you, as the owner of record, are hereby authorizing Barron & Jacobs Associates Inc. to act as your authorized agent in all matters pertaining to the building permit application. C. This is a binding Agreement. You may not cancel it except as stated. This Agreement covers and supersedes all conversations, statements and agreements, expressed or implied, between the parties, their agents or representatives. You, the Buyer, may cancel this transaction at any time prior to Buyer Date midnight of the third business day after the date of this transaction. 6/1/12 See the attached notice of cancellation Buyer Date form for an explanation of this right. Seller retains an equal right to cancel. 6/1/12 Barron & Jacobs R resentative Date ************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** • Designer /Salespersons Registration Numbers ❑ Cecil R. Jacobs MA HIC 100809 Ci Christopher R. Jacobs MA HIC 100809 CT HIC 0518617 CT HIS 0554397 Barron and Jacobs - Key Personnel Contact Information: Office Cell Home Office Manager: Sandy Scavotto 413.586.8998 President: Cecil R. Jacobs (Jake) 413.586.8998 413.250.2357 413.584.4447 Purchase Agreement Page 18 of 18 Barron & Jacobs Associates Inc. Contractor's For Office Use Only May -12 Design.Build.Remodel License Numbers: Agreement #�L) 1 General Contractors MA CSL 030739 Checked by 70 Old South Street MA HIC 100809 ❑ Plot Plan included Northampton, MA 01060 CT HIC 518617 ❑ Need Plot Plan Tel. 413.586.8998 ❑ Dig Safe white flags posted Fax. 413.585.8715 py Agreement is: ❑ Cash Email: infoCa3barronandjacobs.com © O ❑ Financed Job Site Phone 413.586.2093 His Work PURCHASE AGREEMENT Her Work His Cell 413.244.7530 i] ORIGINAL (Designer's Copy) Her Cell 413.244.9518 ❑ COPY (Buyer's Copy) Fax Email Name of Buyers: Mark Gerstein and Betty Mitchell Job Site Address: 56 Revell Avenue, Northampton, MA 01060 Mailing Address: (if different) SELLER AGREES TO FURNISH AND INSTALL THE PRODUCTS AND SERVICES LISTED BELOW: Prospectives, Proposals and Reference Drawings dated N/A may accompany this Agreement. These drawings are prepared to assist the Buyer in visualizing the project and are not intended to be construction drawings. Actual dimensions may deviate when actual construction takes place. Should construction drawings be required by code officials, they will be prepared by the Seller at no additional investment to the Buyer. In some cases, items or objects are added to the prospective drawings for visual purposes only. These items or objects may or may not be part of this Agreement. The Purchase Agreement will identify items that are included. BRIEF DESCRIPTION OF WORK: 1) Strip existing siding on house and garage, re -side with Hardi Plank and wrap all trim with aluminum. 2) Two new exterior doors, (1) custom made. 3) New Mahogany treads and risers. 4) 5) 6) Date prepared: 5/31/2012 Purchase Agreement Page 1 of 18 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : H 12151 Pi1l%i - k - J/ 60 5 License Number 70 01 still Tt s1. N o ii PsM P TON 1 M As v 1 0 11 -10 - t ?- Address Expiration Date (ti 13) 5 6 - 2111 8 Signature Telephone i t . - :u( -n` C• ° ;; : > i . _ - Not Applicable ❑ SAr9 c't4 AND JAGOfr35 0G -iM S 1hi& IOp 3O1 Company Name Registration Number 70 Okp S0 v1'ii 51,. MVPTOM 1 MA Photo 6 - 19 Address Expiration Date Telephone 613, 4 — Vi c )? SECTION 10- 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 No ❑ 11. , Home Owner Exemption 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) J Roofing El Or Doors El Accessory Bldg. ❑ Demolition El New Signs [O] Decks [[J Siding [J Other [,1J Brief Description of Proposed Work: S1 to £P51116 61DiN4 ON HOE • JkND atkIslR4t R� -5rOC• Wititki2Dl i2VRPAP tR t" 000,(4/ ckf PI-A6e 2 );xTt:p_Wo. poO Alteration of existing bedroom Yes & No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet ea., if New house and or addition to existinu,ho complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? 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 I , SE 4%0 o P 4v Pic IS or Iic ) 304/110t4 8 , as Owner of the subject property hereby authorize $4.c & J u) i,5 Assoc-ikivs t Icy to act on my behalf, in all matters relative to work authorized by this building permit application. 5 SPY or A4020-1. rif t$ fWF IE <S e'rI O N B Signature of Owner Date Pik: ice- ft• jibcy,oas , 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. GH 1Z.161 - DPii 2 -- lz - Print Name hA 6 2- Signature of Owner/ nt Date Section 4. ZONING AU 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:' , , R. L: R: Rear Building Height Bldg. Square Footage Open Space Footage (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 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES Q 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 Q NO IF YES, describe size, type and location: !' D. Are there any proposed changes to or additions of signs intended 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. o RECD VE �� '' City of No rthampton Status ofP�a � _ , Building Department Cu rb Cu t/I rl e�+ ay Pe jull 212 M ain St Sewer/Septic A Gila fixes tt l x ,r t t 14 'ZQ�2 Room 100 VVaterNVell Avai l ili orthampton, MA 01060 Tiwo is of f Pl ans _ _ , w,,rr r4 , pfit rte 413- 587 -1240 Fax 413- 587 -1272 Plat/Site Plana ' DE s E S MAC -` 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 .56 le-v6-1.1. AVM.. Map Lot ;Unit 14 01 tIA M P - co N t NIA 010 (i 0 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: MAP Cc t%IN Aaao 'L l Vi ITGN fri-i. 56 tz - ,1 'A, Av- . t 14.0 IKTH AMIPTDN Name (Print) Current `6, - e7- vl 3 C50 LcpY of Aetg0 MF,ilt 6c&-fort e P4 lE vF 1.0 T Signature 2.2 Authorized Agent: ghgt2-0N A.. . A,cols A OC- pTVS, rOG. 7o 01 ' sf. 'No izi tPx1 N Name (Print) Current Mailing Address: 6 6V Cope( oG per. , Emf $F,�Tiot•I t PA 12 of 1 % (v3) 5'36 - S`iR 8 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4 51,000- 00 (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 = (1 + 2 + 3 + 4 + 5) 4 Sy , o ©O• cr) Check Number /CO ` Kg 41 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 56 REVELL AVE BP- 2012 -1121 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 259 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit # BP -2012 -1121 Project # JS- 2012- 001920 Est. Cost: $54000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BARRON & JACOBS 60475 Lot Size(sq. ft.): 6751.80 Owner: GERSTEIN MARK H & BETTY L MITC Zoning: URB(100)/ Applicant: BARRON & JACOBS AT: 56 REVELL AVE Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586 -8998 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:6/14/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE HOUSE & GARAGE SIDING & 2 EXT DOORS 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 6/14/2012 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner