38B-260 (2) SIGNATURES
",y 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 Client to
at any time prior to midnight of the third
business day after the date of this transaction. — / /
See the attached notice of cancellation form lient Date
for an explanation of this right. C
Seller retains an equal right to cancel. -:42
Barron&Jacobs Rep tative Date
Desianer Registration Numbers
El Cecil Jacobs MA HIC 100809 ❑ Christopher R.Jacobs MA HIC 100809
CT HIC 0556380 CT HIS 0554397
Barron and Jacobs-Key Personnel Contact Information:
Office Cell Home
Office Manager: Sandy Scavotto 413.586.8998,x100
Vice President and General Manager: 413.586.8998,x103 413.250.6677 413.665.9113
Chris Jacobs `1
President:Cecil R.Jacobs(Jake) 413.586.8998,x101 413.250.2327 4 4-544: -Z_
Purchase Agreement
Page 38 of 38
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The Commonwealth of Massachusetts Print Form
Y= Department of Industrial Accidents
a Office of Investigations
-I"—`�_
'7-7 = I 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):
l.aI am a employer with 11 4. ❑ I am a general contractor and I
employees (full and/or part-time).
* have hired the sub-contractors 6. F-1 New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ 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
q ]
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#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: Webber & Grinnell Insurance Agency, Inc.
Policy#or Self-ins. Lic. #: W MZ$too V:54 5 01 Zol 3/wm Expiration Date: 3/1 /2015"
Job Site Address: Jru RAVE LL AJE N 0kTHAM Pt01Q M A City/State/Zip:_�ORT4mftoo t M (a(Do
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the,#4ins and genalties o f
,eer'42 that the in ormation provided above is true and correct.
Signature: Date �6 2
Phone#: C�►i3� 5g oig—t$
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 Supervisor: Not Applicable ❑
Name of License Holder: 3blcoss e5—o(oo y Ir�J C
1 License Number
'10 Oup Sau i M SAREET OR-11-IAM PToN . NIA 010 n H-10.' 0 N
Address Expiration Date
(N13) 5?G,$91
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
SARRO► 100909
Company Name Registration Number
I O ao soUTN TgE nn ET NCATHA&AprotQ, / t1 010ron C9. ,D3. a01 G
Address Expiration Date
Telephone �1 •SBG•8998
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 4E9 Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[O] Other[O]
Brief Description of Proposed
Work: M >qS'C IqG VItCHEO REMOPEFL ExISTlK16 O N WA. M. iNOIIP& - TIC(, �I7Zt/gN T()
�:Q" !6A tO. 3JiL0 WC J IjJbt,71,ItTE.,? DDitwnl 00 TR05r' (ALLS t:ok 4e,,j kivwet4 Wilu VCcrc MKnKY.
Alteration of existing bedroom Yes No Adding new bedroom Z2t< Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet 14I
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 I >WSTW16, Af tW
c. Is there a garage attached? Nip
d. Proposed Square footage of new construction. IJr3 __A Fr_ Dimensions
e. Number of stories? STORY 6a Rcur t..)M.�
f. Method of heating? G*s&adkRM Fireplaces or Woodstoves N 0 Number of each
g. Energy Conservation Compliance. Yes Masscheck Energy Compliance form attached?
h. Type of construction WOOD
i. Is construction within 100 ft.of wetlands? Yes >w,/ No. Is construction within 100 yr. floodplain Yes x No
j. Depth of basement or cellar floor below finished grade I
k. Will building conform to the Building and Zoning regulations? X 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
1, Tovp IGERG1JIMc� ,as Owner of the subject
property
hereby authorize UUARRON L 3koR-�" 4550C(4-tF51 .:INC
j at o y behalf in all matters rela've to work authorized by this building permit application.
tu a of Owner Date
I, DARRpJ 7AQBS -As5or_( tTt'S, -VC. 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.
CHRIST-oVw . Q.
Print Na
Signature of Owner/Agent 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 % jr{ S6t rl. 2,055 Sri;;',
Frontage G
Setbacks Front 13%
Side L: 1y, " R: 1" L:a3 Q" R: ,Al'
Rear
Building Height 33� I�` 310
Bldg. Square Footage6 '� % }53 �Q,/
a
Open Space Footage p 0 ►�/� n �N
(Lot area minus bldg&paved 5513 Cp -4 51#40 6 `•T/,
parking)
#of Parking Spaces "AME 54""E
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOW 4 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO W DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® 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 is
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r�nrera� t�i#y�;
City of Northampton
of 0'e
Building Department + fi
212 Main Street
? Room 100
rthampton, MA 01060
OCT 24 2�
on �; � -587-1240 Fax 413-587-1272 ` r
� .:; ✓ ,%�y yr; '�, ^^s� 3
Electric Plumbing �, r
- amt pectf
�0 CSRI TRUCT,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
5q REVELL AVE Map Lot Unit
N0 KTN A MpTO N 1 MA 0 060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tom D1 GJti'Q o w 1 M17 EN R M-L 6VP- WR MPTON)MA
N e(Pr nt_) Current Mailing Address:
� � ✓-�� �X�� p tto�• '04131
Tele 586-S8�'7
hone
Cec.Lt
Signature
2.2 Authorized Agent:
URON � 34co S ASSOC I PIES ,-TN C- 70 04.0 6011-151 RElt-1,4kMM'PT
Name(P int) Current Mailing Address:
✓ (q13) 5S6-SYgB
Xgnure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building I()q' 7(o (a)Building Permit Fee
2. Electrical 3c Jr— (b)Estimated Total Cost of
` Construction from 6
3. Plumbing 7,o lo. Building Permit Fee
4. Mechanical(HVAC) ,
5. Fire Protection
6. Total=(1 +2+3+4+ 5) ( `a, 7.0 Check Number
This Section For Official Use Only
'r Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0477 �C_
APPLICANT/CONTACT PERSON BARRON&JACOBS
ADDRESS/PHONE 70 OLD SOUTH ST NORTHAMPTON (413)586-8998
PROPERTY LOCATION 54 REVELL AVE
MAP 38B PARCEL 260 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 15 X 10 ADDITION(FULL BATH/BEDROOM,DECK ENTRY)&
REMODEL KITCHEN&DINING ROOM
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included: r
Owner/Statement or License 60475 1,7
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
y
Signature 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.
54 REVELL AVE BP-2015-0477
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-260 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2015-0477
Project# JS-2015-000909
Est.Cost: $127675.00
Fee: $818.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BARRON & JACOBS 60475
Lot Size(sq. 1): 8058.60 Owner: DIGERONIMO TODD&CYNTHIA C SIGDA-DIGERONIMO
Zoning:URB(100)/ Applicant. BARRON & JACOBS
AT. 54 REVELL AVE
Applicant Address: Phone: Insurance:
70 OLD SOUTH ST (413)586-8998 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON.111712014 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT 15 X 10 ADDITION (FULL
BATH/BEDROOM,DECK ENTRY) & REMODEL KITCHEN & DINING ROOM
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 Sisnature:
FeeType• Date Paid: Amount:
Building 11/7/2014 0:00:00 $818.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner