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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 April 18,2013 (the"Contract").
Pursuant to the provisions of Section 3.1 of the Contract,Contractor shall commence construction
on or before April 23 ,2013 subject to the contingencies in Article 3.1.
The WORK shall be completed by Contractor on or before June 1 ,2013,subject to such
delays as are permissible under this contract.
The Commencement Date and Date of Completion stated in this Notice to Proceed shall be
incorporated by reference into the Contract.
Owns)
X
AGREED T ;
Contractor
I:
It's esident
CIIAGNON ByILDING&REMODELING tic
Dated: April 18,2013
,I
Contractor Initials Ox‘ners initials: /-
Pagel or I s Copyright O 2013 Chagnon Building&Remodeling LLC
Created on 1.I S.:O H 9 33 nU AM
(leis 13m11rowe Contract
1 rte i.utntnunweuttn u1 ivlu„sucnu,eto I,
,i r
Department of Industrial Accidents
- t = : Office of Investigations
-, ,,'Z 1 Congress Street, Suite 100
�
.'` Boston, MA 02114-2017
,93:44.- - `- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (H46-NOA/ e c e _l /,t-t- p re '.Vd--z_f
Address: 9/ 5XYCkagi() . AI
City/State/Zip: A/4-0/t. ,/1 O/o 3 5- Phone #: <-./73 -05?-arm
Are you an employer? Check the appropriate box: Type of project(required):
1.E3<rim a employer with a 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. remodeling
These sub-contractors have
ship and have no employees 8. (i 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.F1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] -- c. 152, §1(4), and we have no
employees. [No workers' 13.❑ 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: /1/146A-1 F/`1,f t. eitcbA/VAty'
Policy#or Self-ins. Lic. #: Expiration Date:/
Job Site Address: / / 1eACr r.5-&el A City/State/Zip: ‘et-'05- /CM-
/
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 u ider the pains and penalties o per'ur that the in ormation provided above is true and correct.
irSignature: .�R / / Date: 9 okJ`—/3
Phone#: 4///3 ” 0-69- G l 8
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#:
•
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, PeILAA/A VOA, a 5� as Owner of the subject property
hereby authorize -zl +� C Kim to
act on my behalf, in all matters relative to work auth rized by this building permit application.
gee C 5-19A- sr
Signature of Owner / /
9 Date
I, U` Py c61/1-&/va/L. ,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.
6
Print Name
Signature of Ow r/ gent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: V4 ay C#46/u 6o/
License Number
9( 5)6644-l3AeCj- p_ / t���0/,�y ,/' a'o 3 j
Address l / Expiration Date
Signature Telephone
SECTION 13-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 build' ermit.
Signed Affidavit Attached Yes E No 0
•
Version1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable COY'
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor �J-
C// 6z-AioA 1 G'lGL)//'4 feemc� e4,,C. �G C Not Applicable ❑
Company Name: J
Responsible In harge of Construction
4'/ C(-r6/idcf �/ /44D/el , tin C1e3 S
Address
/3 KiLt
Signa ure Telephone
K-:
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
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 Q YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO a. DON'T 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 NO 0
IF YES, describe size, type and location: (b/,po y, /Le/�� ky3D
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.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. PP
Of Proposed Work: �p ��� •• l /`"rJ� / ��i ��
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 CI A-2 ❑ A-3 CI 1A I 1:1
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1St 151
2nd 2nd
3rd 3rd
4th 4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public gi— Private El Zone Outside Flood Zone Municipal E On site disposal system El
,
' Versionl.7 Commercial Building Permit May 15,2000
Department use only
~.,_ City of Northampton Status of Permit
RECEIVED Building Department Curb Cut/Driveway Permit -
' 212 Main Street Sewer/Septic Availability
APR ROOrO1U0
�~' ��~� No�hamobon. MA01O0U Two Sets of Structural Plans
Jhoe413-5R7-124O Fax 413-587-1272
~'�' n"��"'"�'"»n�ovm�
__� ""
NORTHAMPTON,
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
� �� �� �� �
SECTION 1 -SITE INFORMATION pERti | / � /U �Y � / �_�`�jyau
1.1 PropartvAddreao� This section to be completed by office
-- -
Map Lot Unit
/ v 7oe&4�� 6-6-ee-r
^^ Zone Overlay District
�� �c�)-,� '
// /
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2J0wnerofRecond:
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Name(Print) ' j Current Mailing Address:
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2.2 Authorized Agent:
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Name(Print) Current Mailing Address:
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Signature _~.^ c�/=~~f Telephone
SECTION 3-EST|K8AJED �UNSTRUCT|�}NCOSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit app|ioant
1. Building �/\� �� (a) - --- -
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2. Electrical � c�,�� e� — — / (b) EoUma�dTo�| Cm�uf �--'----- � - `
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3. Plumbing ' ' 8uUdinQPermbFee
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4. Mechanical (HVAC) [-- ---- - �� 5 �~ _�y
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5. Fire Protection
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6. Total = (1 +2+ 3+4 +5) /6, 300 �s' Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
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Building Commissioner/Inspector of Buildings Date
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1 FLORENCE ST UNIT 1 B P-2013-0754
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-093 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-0754
Project# JS-2013-001301
Est. Cost: $33000.00
Fee: $198.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GARY J CHAGNON 060175
Lot Size(sq. ft.): Owner: GEIS PENNINGTON
Zoning:URA(100)/ Applicant: GARY J CHAGNON
AT: 1 FLORENCE ST UNIT 1
Applicant Address: Phone: Insurance:
91 STOCKBRIDGE ST (413) 259-6785 WC
HADLEYMA01035 ISSUED ON:3/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & DEMO INTERIOR WALL -
AMENDED 4/26/13 - REMODEL BATH
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 3/8/2013 0:00:00 $198.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner