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38A-004 (5) ARTICLE 23 TERMINATION 23.0 If the Contractor shall: (a)be adjudged bankrupt, (b)persistently or repeatedly refuse or fail,except in cases where extension of time is provided,to supply enough properly skilled workmen or proper materials to perform the work, (c)persistently disregard laws,ordinances,rules, regulations,conditions of any public authorities having jurisdiction over the WORK,or (d)be guilty of material violation of this Agreement, then the Owner shall be entitled,upon seven(7)days prior notice,unless the Contractor shall cure such violation during said seven(7)day period,to terminate this Agreement and take possession of the Site and all materials and equipment thereon and finish the WORK by whatever method Owner may deem expedient. ARTICLE 24 GOVERNING LAW;EFFECT This Contract shall be construed and enforced in accordance with the substantive law of the Commonwealth of Massachusetts without giving effect to the conflicts or choice of law provisions thereof, and shall have the effect of a sealed instrument. This Agreement executed on the day and year first written above. Contractor CHAGN N BUL�ING& ODELING LLC By Its Presid Owner Contractor Initials.14, Owners Initials: Page 7 of 12 Copyright®2014 Chagnon Building b Remodeling LLC Creamd=6)16/2014 3:20:00 PM Woolfm 1EFf SID@1G and WQJD C()MRACT 061614.doca The Commonwealth of Massachusetts Department of Industrial Accidents a Office of Investigations 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): C/{rryUy Address: q/ vk 4—,61- Y��,� (?.. . City/State/Zip: e Ol0 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.Ell am a employer with @L- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working or me in an capacity. employees and have workers' g Y P tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 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.] c. 152, §1(4), and we have no employees. [No workers' 13.[Other comp. insurance required.] *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 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 Policy# or Self-ins. Lic. #: dcol Vz ?Oqa� Expiration Date: Job Site Address: 61 Borls PY Aho City/State/Zip: N M,L©W6 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 u er the pins and penalties ofperjury that the information provided above is true and correct. Signature: Date: 17�Oy Phone #• �3' ' � Ofcial 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 7 8.1 Licensed Construction Supervisor: ! Not Applicable ❑ Name of License Holder: rr� :R- 'j-- cdf�/�� t 06 a l a License Number Address �� Expiration Date S wila ture Telephone 9.Registered Home Improvement.ContmOor Not Applicable ❑ e—M,6r&W, 43 u,�v;, , it 1, ," /o 7S/ Company Name �— Registration Number 1044- Z Address Expiration Oate Telephone y/3`�Jl'�or�ISJ 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) ❑ ]_Roofing ❑ Or Doors [!I Accessory Bldg. ❑ Demolition New Signs [0] Decks [M Siding[�,]/Other[[:I Brief Deperip ion of Propo ed Work: D1x h t S s %7ri9✓c�i t ��r1 C'j" Gc ,�yU �, % /"l� rVLrt✓ i ti Alteration of existing bedroom Yes_e,�No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 4-�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, 9/Z /QC.j�dj �/(�y�� as Owner of the subject property ^�- hereby authorize to act on my behalf, in all mattefs relative to work authorized by this building permit application. signakre of Owner Date �, c�t� c���4Cti as Owner/Authorized Agent hereby cTeclare ifiat 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. Print Name ry Sign re O d ent 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: _ 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 MM (,7y YES Q IF YE$ date issued: IF YES Was the permit recorded at the Registry of Deeds? NO 0 DON'T 14VOW 0 YES 0 IF YES enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T MOW 0 YES 0 IF YE$ has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES NO I F YES, descri be si ze, t ype and I ocat i on: D. Are there any proposed changes to or additions of signs intended for the property? YES NO /7"A- 0 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ Department use only ty of Northampton Status Of Permit. � ilding Department Curb Cu6vewajr Prti#. t ! 12 Main Street Se+ rJSeptivailabii 23 •� Room 100 Water�WeltA�r�tlabNlt�. _ _,Mort ampton, MA 01060 Two$61ts,of Strwuralplans Electric.Pij' phane 41"Srg 7-1240 Fax 413-587-1272 €lottsite Plans 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 C9 13 02TS Pi.f AVA4 Map Lot Unit o!U Zone Overlay District " l� Elm St.District GB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pant) Current Mailing Address: -�l yi3 ee Cwy p� j�, / /��c r Telephone Signature 2.2 Authorized Agent: 1;:Ap-V T'- 9/ -510cm n ) f Name(Print)f Current Mailing Address: 7'13 2 9 f%O Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by pe rrnit applicant 1. Building (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) // 30J lCheck Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/inspector of Buildings Date 2 BURTS PIT RD BP-2015-0020 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 38A-004 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 windows/siding BUILDING PERMIT Permit# BP-2015-0020 Project# JS-2015-000028 Est. Cost: $11400.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GARY J CHAGNON 060175 Lot Size(sq. ft.): 11412.72 Owner: WOODFIN ELIZABETH&DEIDRE CUFFEE-GRAY Zoning: 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.•71212 01 4 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL SIDING & REPLACEMENT WINDOWS 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 7/2/2014 0:00:00 $70.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner