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18D-011 (2) I COOKE AVE BP-2017-0765 GIS4: COMMONWEALTH OF MASSACHUSETTS Mak: ISD-01 l CITY OF NORTHAMPTON Lot: -OQI PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit p BP-2017-0765 Proieet d JS-2017-001277 Est.Cost: $2600.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BAYSTATE RESTORATION GROUP 056785 Lot Size(sa. ft.): 15899.40 Owner: WATSON DONALD E JR&TIFFANYJ zaninz URB(100)1 Applicant: BAYSTATE RESTORATION GROUP AT: 1 COOKE AVE Applicant Address: Phone: Insurance: 69 GAGNE ST (413) 532-3473 WC CHICOPEEMA01013 ISSUED ON:1211212016 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE& REPLACE EXISTING METAL PORCH ROOF, REPAIR DAMAGE TO SHEATHING & GUTTER POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.Y.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough; House tt Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: il: 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 12/12/2016(1:00:00 $65.00 212 Main Street.Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _ - Department use only � City of Northampton Status of Permit: Building Department Cum CuUDrveway Permit ?f116 212 Math Street Sewer(SeptitAvailat5iltyi� Room 100 Water/Well Availability- Northampton, vailabilityNorthampton, MA 01060 Two Sets at Structural Plans_ lion- 413-587-1240 Fax 413-587-1272 'Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION ( _ I C[' 1.1 Proper Address: This section to be completed by office I1r (ook¢, A-vi MapLot_ Unit (""111+oLi4rAk^O 414 0 0L0 Zone Overlay District Elm Si District CE district., SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: .9- Name Name(FrtnQ C r=nt Mal'm Adtlress' Signature NaPhone 3 p 0etp - 6 Z 7 /�'� 2.2 Authorized Anent J.74�r� k p ht &v dict/p0 11 wd 69 or hif - - Mame(Purl Curren:kialing Address: 1' t 03__?7e-asac signature ieepnone • SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed„� by permit applicant 'f� 1. Building \/S40o, Orj (a)Building Permit Fee ( 2. Electrical (o)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �j 6. Total=(1 +2+3+4+ 5) Check Number 13GV 27 lS This Section For Official Use Only Building Penmt Number: Date Issued: 7 - 9 Signature: /2 r Budding Comnissioner/inspecter of 8uidinge Date Section 4. ZONING All Ynformatton Must Be Compinted. °ermrt Can Be Dented Due To Incomplete Information Existing Proposed Required by Zoning This=Nam to be Oiled in by Building Depamnent Lot Size � � .._ Frontage Setbacks FrontSide Rear Building tieeght _ Bldg.Square Footage -_ - Open Space Footage (Tot ma Mims bldg&paved _.... _ ... .arbn,f_-... f — #of Parkin• Spaces - ---- Fill' _ .. .... rvoiome S Locarnm! -....___. _...... _. . __ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES Q W YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds/ NO O DON'T KNOW ® YES O IF YES. enter Book - Page. and/or Document it B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW C'Sl YES O IF YES, has a permit been or need to be obtained from the Conservation Commission, Needs to be obtained O Obtained O , 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 O IF YES, describe size, type and location: E Will the construction activity disturb(Gearing,grading,excavation.or filling)over I acre or Is it part of a common plan that will disturb over 1 acre? YES O NO 5R IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ l Replacement Windows Alteration(s) n Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs ,DI Decks (D Siding[MI Other'.C1 Brief Descriplipp of Proposed Work: M04t- -f' k._ Writ ` f e twerp akt ZAP /tt t l4t ;{Itfj, W✓ Alteration of existing bedroom Yes A No Adding new bedroom Yes x Noy Attached Narrative Renovating unfinished basement Yes '\ No Plans Attached Rod -Sheet Ga.If New house and or addition to existing housing, complete the following: a. Use of building:One Family Two Family Other luisdrip/n1'br• 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 a. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction kibd iW Is construction within lOO ft.of wetlands? Yes No. is construction within 100 yr. floodplain Yes No I. Depth of basement or cellar leer below finished grade k. Will building conform to the Budding and Zoning regulations? x 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 —Cdf.144.71/ ,L_ ,as Owner of the subject Property "}"�' my inera relative to worky�� �'' ll J herebyauthorize to act on behalf,/ all a authorized by this building permit applicatt� . Signature of Owner • Date • as Owner/Authorized Apert he�are that the slatemen 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. �e . . Print Na' Signature of Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: {/��� y� Not Applicable i / —r Name of Oconee Holder'. Mur �r A frib c S V�b /8'S �/ License Number -., .S.'. Uzsr/ 1— a- _ Neel. A,/ 0/07} 9—* —ek/9 Address • Expiration Oalci 1 erl- Signet fu..., l.r-. TMepnone 9. Re istered Home Improvement Contractor. Not Applicable ;f° s ire 1-nrq}a'o,u 6nnv� ..—. t 8 L176 Com' an ame Registration Number I 69 Glipe SP: lI - t Ow Address ; -Tj 3a-' 47J Expiration Date Chi-An // r / _Telephone SECTION IR WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(5)) 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. I Signed Affidavit Attached Lei, I No 1 —— — 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 786. Sixth Edition Section 1083.5.1. 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 he,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-war period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that hetshe 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,von may be liable for persons) 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 City of Northampton 212 Main Street. Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 1 6eke± /4v( —Ids�e- 4 ,,., ,44 plo(to The debris will be transported by: 6nn2,/ SSC 11/ '(ej The debris will be received by: 140 /�Sif Sb t A - qh?m Building permit number: Name of Permit Applicant IC • , , 1. A71-5- olo(G Q Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations t 1 Congress Street, Suite 100 Boston, MA 02114-2017 c www.mass.gov/dia Workers Compensation I nsuranceAffidavit: Builder Contradors'Electricians/Plumber s Applicant Information R Please Print Legibly Name (Business/OrganizatiowIndividuaq: Sag r'. Address: fir City/State/Zip: (fl f9ie abig 0/014 Phone 4: -//3 - 513A - .34.3 _ Are you an employer? Check the appropriate box: Type of project (required): 1.[N I am a employer with O.. 4. C I am a general contractor and 1 _ employees (full andior part-time).* have hired the sub-contractors 6' —New construction 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. enployees and have works' 9. Building addition [No workers comp. insurance comp. insurances required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.J I am a homeowner doiny,ail work officers have exercised their I 1. � Plumbing repairs or additions myssf. [No workers comp. right of exemption per MGL 12.A Roof repairs insurance required.] t c. 152,§1(4),and we have no employees [No workers 13.7 Other comp.insurance required.] 'Any appli cent that checksbat#1 mu&&en fill out the sect on blow&revving theirworkers' compensationpWicy inform&ion- 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicffing such. 'Contractors that check this box must attached an additional sheet showing the name of the suh'contraetors and state whether or not those entities have employees. If the sub-cvntrators have anploycg,they must providether worke's amp. policy number. I am an employer that is providing worker compensation i nail-ante for my employees Blow is the policy and job Ste information. Insurance Company Vame: A. re 7 Policy # or Self-ins. Lic. #: (V O )) ,) 0010 I Expiration Date: / - `� DI 7 Job Site Address: 1^ c"oak-e z4k L City/State/Zip: /Uoyfltam gp/06O Attach a copy of theworke en e compensation policy declaration page(shawing 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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. !do hereby certify under the pains and penalties of perjury that the information provided above t is true and correct. Signature:. _tiZA-C_ _..... Date: /al-- /- �O/C Phone#: // 3" 5-3c)--_ 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): I.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other _ i1 ORE)e ACCERTIFICATE OF LIABILITY INSURANCE �r� j oATE:MmtDmvvwl 10/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND) EXTEND OR ALTER THE COVERAGE AFFORDED EY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). I PRODUCER CONTACT Virion Lentes Berkshire Insurance Inc. RxoNeo _,AI, (413)935-1200 plc Nm. Insurance .roup, rArc - - M13ssY-raD 138 LongmeadowSO- atLFlEss:mlenteu@berkshare.lasurancegroup.core INEURERfs AFFORDING COVERAGE ' NAlc 4 _ _.._ Longmeadow MA 01106 :N,sugERA:nhiladelphid Snsuxance Wsusto 1IdSURER8 Ok10 .YdZiRE LL0CSd1tY LRS. Baystate Restoration Group, LLC I INSURER C. 69 Gagne St INPRPER0. INSURERE: Chicopee H . 01013 Pt SURER P. COVERAGES CERTIFICATE NUMBER CLS 61013460"16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. "" AEI°L- JW POLICY EF ' POLICY EYP UDR Tin OF 3NSURANCE ps0.PINT PSVCY NUMBER 'fl YYt AteCO ' MPWOIRYYY}' RANTS _ n' COMMERGM.GENERAL LAWYUTY I ERE+OCCURRENCE 3 1,000.000 • CWMS.MAOE X OCCUR JAIMGEs iETO oc RENTED 5 100,000 A PREMISES RNNPPORS4_ 2Ezta56294T I10/T/2016 10/T/2017 'mer,EXP Any cis spoon' 5.0001 RONStNAL 8 ADV INJUR! S1,000,000 Sea AGoRwAiEL:Mrr.wp ES PER GENERAL AGGREGATE 3 2,000,000 X ?CLOYI P90. .ECT ILOC PRODUCTS•COMPP)P AEG]S d.000,0001 OTHER II I $ AUTOMOBILE LIARILITY RO•C .INED SINGLE SPRIT1.4.PANcodenti N APR AUTO 90ONY NJURY;Mf Ver-sen) i3 ALL TOS e6. �— AUT BBCDLY NAIRY Pt RoPen0 3 I HIRED AUTOS • NCNOWNED PROPERTY DAMAGE 1 $ AUTOS TR%?cadent) $ IX UMBRELLA LIAR H.OCCR [ I EACH OCCURRENCE E 1 000,000 0 I EXCES'A UAB CLAMS-MADE S l .AGGREGATE ,S 1 DED 1 IRE-WTION5 puB559655 1017/'X16 LU/7/2017 l g WORKERS COMPENSATION I NI ER 0TH' AND EMPLOYERS LIABILITY YIN TIfTI ANY PROPRICORPARTNERJEXECOTIVE e.. EACH ACCIDENT IS OFRCERTMEMNER EXCLUDED IA (Mandatory NNI EL DISEASE EMPLOTRE S R 5[ DESCRIPTICRI OR OP.RATICN.,.Neiow B I Pollution/ 6 o_oteae;coal BPIC562869 1 10/7/2016 : 10/7/2017 AAR 1,000,000 L1eNctlde Der clam Sr000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES ACon tot,AddnNMt Remarks scHeCHAR Amy tie attacIN II Awn space Is rewired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE RIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W ACCORDANCE WITH THE POLICY PROVISIONS • AUTHORED REPRESENTATIVE Marion Lenta3/MLENTE a21h4.T4 _ lQ t >l e 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101). The ACORD name and logo are registered marks of ACORD INS025nemint gin,»„ //4 jell /aoeun \_Of c rConsumer Affairs&BusinessR g l 1 i , itS -I(3OME IMPROVEMENT CONTRACTOR eegrstratwn 1809]8 Type' xpiation 11/1912016 LLC BAYSTATE RESTORATION GROUP, LLC. MARK DAVIAU 69 GAGNE ST �� CHICOPEE, MA 01013 Undersecretary Massachusetts Department of Public Safety r Board of Building Regulations and Standards License: CS-056785 • Construction Supervisor MARK R DAVIAU 76 GILBERT RD G�RR';},rpt SOUTHAMPTON MA (LOW ; (psi 1 /L— Expiation. Commissioner 09/09/2017 40Re CERTIFICATE OF LIABILITY INSURANCE °°" °° ��- 01/11/2086 THIS CERTIFICATE I5 ISSUED AS A MATER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, til ENI. OF ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cerllicaie holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. ti SUBROGATION IS WAIVED. subject to the terms and concolions of the policy,certain policies may require an endorsement. A statement on this certificate does not conger rights to the ¢TBncate holder in lieu of sucn endorsemengs). T PRcoucER 00501 -001 - LeneilLavigne S Deady insurance Agency Inc ZEw Esa: (°l9)S 2-3291 :Lea No.: Sal 3)534-0982 PC Boz En nDCh�s: Chicopee, MA 01021 - Nst aitL_a5-9.9 E Nyc,v INSURER A Manic Charter insurance Company VDAC _ 29211 INSURE] NsuPEP a Bayslat Restorapon Group, LLC INSURER fig Gagne Street Chicopee,MA 01012 !NEMRER.p' INSURER E: NTIMIHR COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER: THIS '5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NSURED NAMED ABOVE FOR THE POLICY PEHIOC F INDICATED. NOTWITHSTANDING ANY REQUITEMENT, TERM OR CONDITION OF ANY CONTRACT OE OTHER, DOCUMENT WITH RESPECTTOWHICH THIS CERTIFICATE MAY SE SSUEJ OR MAY PERTAIN, THE INSURANCE AFFORDED EY THE PCIJCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCWSIONS AND CONDITIONS OF SUCH PCLIOIES LIMITS SHOWN MAY HAVE BEEN DEDUCED BY PAID CLAIMS. Non' TYPE OF NSOPANLE $MBR LACY PC LICY-py MCP WVn,. °OUC NUMBER MM1NODN 'IMMOOIYM%TO LIMBS GENERAL LIABILITY EACHOCCURRENCE CMMERCIAL GENERAL''LABIUP' 'DAMAGE ETC DENTED ,PAGAIOMS.AEs accvaenuo CLAIMS-MADE OCCUR MED EYPPPMIT one eaimml 5 PERSONAL re POP INJURY o GENERAL AGGREGATE GENL AGGREGATEIMrT APPLES PER PRODUCTS COMPfOP AGC POMC)/ SCT LTC AUTOMOBILE LIABILn'! CCMDIN©SINGLE LIMIT r Lied acaden0 ANY ALTO. I BODILY INJURY(Borne/son) S _.. ALL OWN© CCHCPULE BODIL''SWAY IP^macddenii'. S AUTOS ADT0.5 HIRED AUTOS 'NON-OWNED PPOPAI I YDAMAGE (EGS'4ded) DMBRE_LA NAB CCCJP EACHOCC'URRENCE EXCESS LIAR I CLAIMS MADE AGGREGATE N�pKO'ERO M EPNESFgiTVIT�CN pT1V AµNyo BAAPpIqO��YFE�riu�p/LJAR0R1LdFH�R' ' x TCRYTfJH E9 A ORICO.ATMENBEPE�CLOOEJ?<EJUVE YvN..NIP... WCV01200e01 1/14/2016 1,14120'? E. EACH ACGDENr 5 500000.00 (Mandatory in NNI - EL DISUSE EA EMPLOYEES 500,000.00 }}YY ee n ee. Policy Coverage Stare: MA BreCOPCNO�OPEPATIONS below I ' EL DISEASE PCUCY UMW ,'.S 500,000.00 Na Member is covered oy the workers compensation polity_ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AImch ACORD IDl,Additional Remvhe SMiodule,if more space is required) CERTIFICATE HOLDER • CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR. TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE BOUCY PROVISIONS. ADn1ORRE°REPRESHir'ATIVE- L D1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD _ All contractors and subcontractors must be registered by the State. Any inquiries relating to registration should be directed to the following: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617)973-8700 YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME YOU SIGN IT. NO WORK SHALL BEGIN PRIOR TO THE SIGNING OF THIS CONTRACT. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD(Yo)BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR.AN EXPLANATION OF THIS RIGHT. - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. d-77/-•'( /1 /L Baystate Restoration Group Date By: IJWe, J 4.l.w" Print ll Owner(s): (\ XX it/za-jf‘ By: Date Duly Authorized By: Date Duly Authorized 3