12-025 J. •
1 332
3n
24" 30" 4{' 36" 42
W361824
r
DW362424R W3036
1
T.-- N
o co TEP2496WD TEP249&
c LO s
try CO
LO 'It SLS36R , 3DB18
CO CO
C.0 -
36" 18" „ 36” - , 42," -
4 4
115 - 8 " ' 18 8"
1':i <1,,,,,,,,,,,,,, si /c designations given are -- _, 1 This is an original design and must not be I Desi 4/28;2012 ,tt
snhjcet to , Onti cation on job site and released or copied unless applicable fee has Printed. 4/28/2012
.idj to lit job conditions- LoWE �� been paid or . job order placed. - - - --
i
11' L3ntind- Mitchell psi.l<it I ei ,
•
r'
192
1 1 tt
3" _ -
33" 30 30 " 9 ", 37 4,t 12 - 24
cO W3018
r
' ' W1236IDW362424R
F3: W3336 W1536� W936 R'
c-- r j MW.HOOD '
Ln = �
N---
O
r
F3: B12L 24.DISHW SB24 TRBD18', 30-RANGE2 TD9R BEPF1' SLS36R
CO
1 1 24" 18" ; 30" 4 �� ` 36
2 2?� 24" 18 30 9 36
8
1 2
255 t, 24 " 43 " ;, 43" — ---
544
a
1 16 16
111 dimensions _sire designations given are This is an original design and must not be Desi 4/28 /2012
subject to vcr- tication on job site and released or copied unless applicable fee has Printed: 4/28'2012 '
E' a
adjustment to tit lob conditions. LOW , l been paid or job order placed.
I
I
L. —
.ID 13ulixd- Mitchell.psi -kit I r'r , 1 -
r '
192"
47 ,. 144 8 "
N
92" 21 a "
-
d.
1 - 47,6 —
0,6 50
- - - - -- 8 - - -- -,-,- -
rn
SBS SBS
CO (.9 r
r0 00 CO
in
PRELUDE
r
',,51,A�11 �L9J 30- RANGE2 T;R.B:6 - 1,' SB24 `.24LfSIJV .1' I,''
v - `��� I,ILVS1 2422 v-
DW36242 1230R W93 W3018 C>'i 53ts.R f , x \ 3'8E \.\ V ` ,-
1
a 35;0" Y , 36 4" t 9 ' —39 \ 18" 24 24" \ 12" 1 ,
54;,, , - 43" i 438 ;, 24' 258
16 1 16
1
24" 12" 37,'" 9" 30" r' 15" - 30 a,, ,. 33
1928
All dimensions _siie designations gig -en are - ' '---____ 1 This is an original design and must not be Designed: 4/28/2012
subject to ve ificalion on job site and released or copied unless applicable fee has Printed: 4/28/2012
adjustment to lit job conditions. It Low E's ___1 been paid or job order placed. — —
.Ill 13uford- ,l1itehell_psi.kit I All
fi
jl =I
1
%
_
':' -, I
II
III
Note. This draNN ing k an artistic ---`- Designed: 4/28/2012
interpretation of the general appearance of f [ L���� i Printed: 4/28/2012
the design. It is not meant to be an e.yact
rendition.
I I
-- ----- - - - - -- - -t- -T— - -
.I1.1 13uford- Mitcltell.psi.kit 'I All I I7rawin, it- 1
STC = COPY
N IF THE CONTRACT TOTAL IS S1_000.00 OR LESS Customer must Pay in full.
r1
CO .IPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS S1,000.00:
Custom er to Pay in Fuli: OR
•
Customer to use the fo:Fo ;ing payment schu!e
1: !Deposit S - b be pa'J uport sign :ng ccntrecr Deposit sho be 1 r3 the total contract price; and
CIS i 21 Payment of S to te paid anytme after this Contract is signed and before corr rn encement of ins'al!ation. [We authorize Lov:e's to do cie of tie fcI o, ng (check appropriate bo b$-
M i:
CU
CO ;_J Charge rnyleur creciit card for the amount of the payment indicated above anytime after the date this Contract is signed: or
ti
J Deposit myour check for the amount of the payment indicaated above anyt'me after the date th s Contract is signed; and
{3) FJral pat of ST00.00 to be
payment paid upon completion of the instal'aGon 3rd both arties' satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND COroilioN CONTAINED IN THIS CONTRACT AND WH ICH FOLLOW
g THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS
00 CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
CO
an NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L, c.142A
M
• LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT !N THE EVENT LOWES HAS A DISPUTE CONCERNING THIS CONTRACT, THAT LOVE'S MAY SUBMIT SUCH DIS-
PUTE TO A PAIVAT E ,' . 1 •+N SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS
AND TI-IE OV 4: EOUIRED TO SUBMIT TO SUCH ARM RATION AS PROVIDED IN M.G.L 0.142A.
By: _Date: G 2c? c?/1Z
owe's • - Centers.
O
1 / 17< 0 / )
By: &O Date: 4 / 7411
C a
ro By: Date: _
3 Co-04n et or Witness
0
THE SIGNATURES OF THE P RTES BOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWES PURSUANT TO M.G.L
.142A_ THE +LWIER F • Y BE PERM1 ED TO INITI •T _PL.:. IVE DISPUTE ' ESOLUT[+N WHERE THE S CTION ABOVE IS N IT P ' •TELY SIGNED :Y THE PA 'TIES.
WITNESS OUR HAND S . r,. ' BELOW THIS 2i DAY OF A - <
Lowe's Name ente /
O BY : _ - l (Seal) D,tiner:_ ��- _(Seal)
Print Name: • } � � C ' � _.. _ Print Name:
(NJ Store 5916 Project Summary (or DON BUFORD Page 3 of 7
`cm
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
cr c4)
5 1 Congress Street, Suite 100
• Boston, MA 02114 -2017
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): Chagnon Building & Remodeling LLC
Address:91 Stockbridge Road
City /State /Zip:Hadley, MA 01035 Phone #:413- 259 -6785
Are you an employer? Check the appropriate box: Type of project (required):
1. 0 1 am a employer with 2 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. n New construction
listed on the attached sheet. 7. El Remodeling
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. n 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. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.] 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.
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: Farm Family Casualty
Policy # or Self -ins. Lic. 4:2001W7205 Expiration Date: 11/14/12
Job Site Address:31 Mary Jane LN City /State /Zip: Florence, MA 01062
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 nder the and penalties of perjury that the information provided above is true and correct.
Signature.[ cL 1 7/ Date: 6 65/
Phone #: 61/3
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 Su ervisor: Not Applicable ❑
Name of License Holder : � C ,�1 ,�L,t-✓L 6 �}`) 7
J J License Number
I 5 - Ottt Ed. l J @ M4 6163c 7 Address Expiration Date
qi3- R3 4?-g3"
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Cri ati /3,I1 /A e �e i e 4,t, //a 757
Company Name / / Registration Number
9i
SiCtCkt3Picir
Address / � Expiration ate
%y ! /"(!t O lt73S Telephone �.3 lQ_
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 t 7-` No ❑
IL - 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 Wjr(dows Alteration(s) F r Roofing
Or Doors L1
Accessory Bldg. ❑ Demolition Er New Signs [El] Decks [Q Siding [0] Other [p]
Brief Description f Proposed / -
Work: U1 4 roiklR �$ it J�_) �t gdz f c s r4.r.di , . 1 1,t3` )
Alteration of existing bedroom Yes 1 Adding new bedroom Yes L No
Attached Narrative Renovating unfinished basement Yes L- No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, 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, i/o/%44L, i) 0u ? rd. , as Owner of the subject
property //'
hereby authorize 6I 1R / T. L' 1414-6 -Kici l/
to act on my behalf, in all mattefs relative to work authorized by this building permit application.
Signature of Owner Date
I. 0 - 3'. C/ �,,A.._ , as Owner /Authorized
Agent hereby decl that the stateme and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed undert pains and penalties of perjury.
Aitl 3. i
Print Name
_ _5., , /------- , a5Aa
Signature of Owner ge t 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 I,: R: I,: 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 /Findin 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 Q DONT KNOW 0 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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 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, exc ation, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb CutiDriveway Permit,
212 Main Street er /S aiiabiiity
Room 100 Water/W ell epti Av(abiiity
Northampton, MA 01060 Two Sets o f Structura Plans
phone 413- 587 -1240 Fax 413- 587 -1272 Pipt/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW FAM DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
- AA- LA) Map l i Lot O7 Unit
Zone Overla District
i
Y
t'are. -c: ,e 1 CB District
rtt
Elm St. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
orteg�j� /�u 1;1' � ! / J�"k e
Name (Print) Current Mailing Ad ress:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address: J
41 3- & .3 7 - 5. '
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost () to Official Use Only
completed by permit Dollars applicant
1. Building (a) Building Permit Fee
2. Electrical CO (b) o
�u i. Estimated . Construction T from tal Cost (6) of
3. Plumbing $ ,SY71 CAD Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 +3 +4 +5) , �C c Ch eck Number
This Section For Official Use Only
Building Permit Number: Issued: Date
Signature:
Building Commissioner /Inspector of Buildings Date
1
File # BP- 2012 -1175
APPLICANT /CONTACT PERSON Chagnon Building & Remodeling LLC
ADDRESS/PHONE 91 Stockbridge Rd HADLEY (413) 259 -6785
PROPERTY LOCATION 31 MARY JANE LN
MAP 12 PARCEL 025 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ' '1i( 4 t/ , t(
Building Permit Filled out
Fee Paid
Typeof Construction: Demo existing Kitchen, reinstall new, replace 1 window
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O ATION PRESENTED:
Approved 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
De •itis �, 4?c..0Z7r72---
Signa .. - of Building Official 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.
31 MARY JANE LN BP- 2012 -1175
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12 - 025 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- 2012 -1175
Project # JS- 2012 - 002007
Est. Cost: $10242.00
Fee: $61.45 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Chagnon Building & Remodeling LLC
Lot Size(sq. ft.): 9975.24 Owner: BUFORD DONALD E
Zoning: Applicant: Chagnon Building & Remodeling LLC
AT: 31 MARY JANE LN
Applicant Address: Phone: Insurance:
91 Stockbridge Rd (413) 259 -6785
HADLEYMA01035 ISSUED ON:6/29/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: Demo existing Kitchen, reinstall new, replace 1
window
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 6/29/2012 0:00:00 $61.45
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner