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03-029 (4) 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 parti their agents or representatives. .a 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. —y/= See the attached notice of cancellation Buyer D e form for an explanation of this right. Seller retains an equal right to cancel. Barron&Jacobs Representative Date ********************************************************************************************* Designer/Salespersons Registration Numbers ❑ Cecil R. Jacobs MA HIC 1008091 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 9 of 9 provn,oris cf NIGL c 4-c-), �.54, i cl condition of tie- Buil'-ding pemilt, all debris Ye,-zliking fro!-11 Ccnstruci govern-d hythNs Buil-Difni f -On P-c3TVFY g Permit shall be dispose-i of 2t a- U--')%N"E- OF 2 p Iropedy hci e nsed soM e f a tc-illity a S de—, r; "j by jp r* C j-1 p a?N" T. TY P 'ari Co4i ttf Ftt USO 0- P E77ONT A.-PP."-(CA.AI7) TOB-T-- T _'� The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations '1 `` ~ '-' 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): 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. I am a employer with 1— 4. ❑ I am a general contractor and I ❑ * have hired the sub-contractors 6. New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box#t 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. Webber & Grinnell Insurance Agency, Inc. Insurance Company Name: Policy#or Self-ins. Lic.#: W MZ BOO G':54 5 O 1201.3/M"M Expiration Date: 3/1 /20K Job Site Address: .2 I I/� � 7i U Vy �b A P City/State/Zip: of�l(Y Vl� I�l\� 'Y'A 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 under the eains and eenaldes o f er'u that the in ormation provided above is true and correct Signature: �( p Date Phone#: Official use only. Do not write in this area, to be completed by city or town offeciaL 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 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: C � 1 � 6J — 060y15- ^ l/� (� License Number �V tT I I / �Vll/ I V I l z0 I� Addr4ss �� W6 6 T Expiration Date Signature 'Teie'phode 9.Realstered Home IfforoveffmA Contractor: Not Applicable a o� 100201 Company z Registration Numbbr Jb 01..E o }i ST_ Nom A o 060 6. 7,/ 1 Add Expiration late Telephone 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"cvas extended to include Owner-oceuuied 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 super%isor.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 Officials 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 forperson(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 aoolicabie) New House F-1 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks [p Siding[r-3] Other[[I Brief Des�ri tiQ��i r s rTA r M o �/ L �` j AA ,�_ �� 1 Work: K 0 t14� J T �l!, Alteration of existing bedroom Yes J No Adding new bedroom Yes V No , Attached Narrative Renovating unfinished basement Yes __No Plans Attached Roll -Sheet Ga.if New house and or addition to existing housing,complete the followinla: 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. 1. 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 �►�/� q I, �Z A2V �'I�/'p �� � U ;�Pl � I as Owner of the subject Property hereby authorize I✓/11 ! lT /"� /-i11�/ to act on my behalf,in all'i atters telativello work authorized by this buildin§permit application. Signature of Owner Date i /� -���� 11,± "V f5 as Owner/Authorized Agent hereby declare that he statetentsand i formati n dTf the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under th ains nalties of perjury. Pri ame / Sign of OwnerlAgk Dat Section 4. ZONING Al Information MA Be Completed. Permit Can Be Denied Due Tolncompletelnformalion Existing Proposed Required by Zoning This column to be fitted in by Building Department Lot Size Frontage Setbacks Front Side L:_ R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage °lo (Lot area minus bldg&paged _ arldn ) #of Parking Spaces Fill: volume&Locaion _. A. Hasa Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW © YES Q IF YES, date issued: WYE& Was t a permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO W DON'T KNOIII 0 YES IF YES, has a permit been or need to be obtained from the Co rvation Commission? Needs to be obtained ® Obtained ® , 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 ® NO 0 IF YES describe size, type and location: E. Will the construction activity disturb(clearing,grading,Ugavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only Gty of Northampton Status of Permit: Bulilding Department Curb Cut/DrivewayPermit _ 8 j212 Main Street Sewer/Septic Availability APR 2014 -,I Room 100 Water/Well Availability, i jNor hampton, MA 01060 Two Sets of Structural Plans Electric, FzO 87-1240 Fax 413-587-1272 Plot/Site Plans 0 Other Specify 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 �lI 604 ���t���v Map Lot Unit •V NOK�AM�TON y`/ A P— 6140 Zone Overlay District I Elm St District CB DiWIO SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: flt/ 9�I�� I Name(Print) Current Mailing Address: J�: MftV I Telephone Signature 2.2 Authorized Agent: G� aG. G jo bW ,5Cq1'R S-_ N6414A.MMN.m Name(Printj Current Mailing ress: Signature ephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be official Use Only completed by rmit applicant 1. Building 0 (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) 57 Check Number This Section For Official Use Only Dte Building Permit Number: Issued: Signature: Budding ComnussionerAnspector of Buildings Date 591 COLES MEADOW RD BP-2014-1032 GIs#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 03 -029 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-2014-1032 Project# JS-2014-001782 Est.Cost: $3591.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BARRON & JACOBS 60475 Lot Size(sq. ft.): 281049.12 Owner: REITT PETER Zoning:RR(100)/WSP(100)/RI(32)/ Applicant: BARRON & JACOBS AT. 591 COLES MEADOW RD Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586-8998 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:41812014 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAI R 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 4/8/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner