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35-224 (2) 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 parties, their agents or representatives. You, the Buyer, may cancel this (1 — (�- transaction at any time prior to Buyer Date midnight of the third business day , after the date of this transaction. p-vL� * ((— l� t' See the attached notice of cancellation Buy Date form for an explanation of this right. Seller retains an equal right to cancel. 2 _ /7- ( 5 - / / a c arron : Jaco • • - . resentative Date ************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Designer /Salespersons Registration Numbers C Cecil R. Jacobs MA HIC 100809 ❑ 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 26 of 26 1/3/2012 RE. Narrative for building permit. 46 Ladyslipper Ln. Florence, MA 01062 Work to include: 1) New kitchen cabinets and countertops 2) Add island 3) Change existing garage metal fire door to a raised panel wood fire door with 20- min. rating. 4) Replace damaged pine basement door with new door. 5) Remove existing viyl floor install new hardwoord floor. 6) Replace existing 3 -inch range hood exhaust piping. New hood with 8 -inch exhaust pipe. 7) Upgrade existing electric and plumbing EAR,. NORT4 II 1 ti 1 :11 1 1 111 11, 0 111111 1 iOrAe \ ■11■1■1 001 - _ ,_ _____ • ` io�i / . %/ P rigs LJ o i .-- II 9 rot 3 mom 1 I i i T f _ _, ___,...„------1______-- oil / ...,,.._.,_ ___..,„....,,,,,.„ ,_ 1 „ , , _ --, _ -----,_ _-_------___ ----__ ,., Alme■ „..::,-----; WI ii_iiii j k \\ Pi== --m ‘ .. .■%: - •i - ..N., ■—■.--:.. IX 8 A h oN B A ��5 Note: This drawing is an artistic 20 ' Designed: 11/10/2011 ®LJR interpretation of the general TECHNOLOGIES J Printed: 12/8/2011 appearance of the design. It is N D ESI(N AMPT not meant to be an exact rendition. O� - ' Ail ®x060 /// 7 hornorskinnA1 l All 1 Drawing #: 1 f _ . I In accordance wftih the provi!F,3,.ons of MGL c 4 - ' - -;34, 1 acknowledoe, as as condition of the Building permit, ati debris resulting from construction activity governed by this Building Permit shall be disposed of at __--, ), I - . (NAME OP FACILITY) I i a properly licensed solid waste facility as defined by TV.-e C III, § 1 1 _ cia ) 1 PT-1! OP PITPE THE FOLLOW C NFDRNUTION: i 1 4 „ ,=.1 -:-.,n ,.. _5 A i'S 0 C., ( cY .4 igf :E OF PERM TT A .P Pi_ ( C A, N T;1 ----LA -/-4. OA _ ( F R OPE.P: TY A D DR ES (J) . • L 'd Q7,-, 1 .c.:).7.c; 57'. Li7 i. Ln: 1 linF pAr.n=;ai in: in, -, _,-.• ,--,-. I r RO CERTIFICATE OF LIABILITY INSURANCE OP ID SF DATE (MM /DDIYYYY) BARRJ50 05/06/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IRM Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens, CPCU HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 75 North Main St. - 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028 Phone: 413- 759 -0010 Fax: 413- 759 -0017 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A EMC Insurance Cos. INSURER B: A. I. M. Mutual Insurance Co. Barron & Jacobs Assoc. Inc. INSURER C: 70 Old South Street INSURER D: Northampton MA 01060 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSN U'L POLICY EFFECTIVE POLICY EXPIRATION LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY 4X4998012 03/09/11 03/09/12 PREMISES (Eaoccurence) $ 300000 CLAIMS MADE X OCCUR MED EXP (Any one person) _ $ 5000 PERSONAL &ADVINJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 3000000 X POLICY 7 JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A ANY AUTO 4Z4998012 03/09/11 03/09/12 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN _ EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR [ CLAIMSMADE 4J4998012 03/09/11 03/09/12 AGGREGATE $ 1000000 _ $ _ DEDUCTIBLE $ X RETENTION $ 10000 I $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY X I TORY LIMITS ER B A N YI PROPRIE ER EXCLUDED? ECUTIVL_ II II WMZ8006365012011 03/01/11 03/01/12 E.L. EACH ACCIDENT $ 500000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 500000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PROOFOF DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 - DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Proof of Coverage REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IRM Insurance Agency Inc. ACORD 25 (2009101) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print Form Department of Industrial Accidents x ,41 = Office of Investigations � ' 1 Congress Street, Suite 100 .1M it 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): Us(' ,tr1 e_ 1 • C S _ (,` Address: l a 0\ 5 Cry . S t. 1 t r L, (. e■ K1 A 01 060 City /State /Zip: Nor sctu 6 A 0 c Phone #: \ s ( L Are you an employer? Check th • appropriate box: Type of project (required): 1. n I am a employer with /S— 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. in New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. gRemodeling t {c ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in capacity. employees and have workers' g any p Y 9. n 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.17 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.n 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: ._ \\ v , 5 �_r;; 4x cL. _ l' CiAt.v \ v‘ , _ Policy # or Self -ins. Lic. #: � 1 \ f 12 %j ( o 6 j� , 0 j C, 1\ Expiration Date: 0 VI ,1 Job Site Address: 646 /SG / pP C6L Z-- City /State /Zip: rlinRENGL, 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 insura = overage verification. I do hereby certify under the sal . and enalties o perjury that the in ormation provided above is true and correct. Signature: WI i7A . 7 7 ' i� �� l Date: 3 1 U Phone #: �-�C � l� Ara - ?3D,2 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 : Ceci R. sacc b GS C License Number 70 Dlc Sot/ .111 Street c(11(14.014n / MA ©I c(o 9/-2-1/2_01s Address Expiration Da ( 13) 524 ' Signatu Telephone 9. Registered Home Im• o ement Contractor Not Applicable ❑ Bc�1'rovt 6( Jacobs ASScC i c(.Ie , S F} C., / oO B 09 Company Name Registration Number 70 OIcf ft Strer� Nertnctmetcn I`/1A o[O &O (0 Address . Expiration date _ / _� Telephone 0 13) $ 6 _ $9`! 8 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) 121 Roofing n Or Doors El ( lier]e—t.ers.J Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I= Siding [O] Other [,I1] Brief Description of Proposed Work: K tole r . Re .r►-1 wc#e I Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes 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, Je e ( c: A re ae rn e, tit �1 2_C 5 f G rt J V 8 , as Owner of the subject property hereby authorize 13 arro 1,1 n c bS to act on my behalf, in all matters relative to work authorized by this building permit application. ..S Cr, 31-eemt -ri • p3 C Sec wn B I2 ./2 (1/I Signature of Owner i J Date I, eC G ) / 7 Pc c_c> , 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. Print Na - Si of e' er /Age• Date Section 4. ZONING AR 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 L'���� __1 - __ �L ________� , Frontage / ;,_ ---------_----_-- Setbacks Front r--7 r--- F-- .---� . '�---- L L:;,... _.1 �' r�--- �--| Side ��_'_-� �__-_� ��_--__/ _~ � �--- ( --- ,----| Rear ._____ __-] L__, Building Height r--- ; --- �---1 Bldg. Square Footage �--- [----- % r---� [---, r---- �--- L. '� '_-_� L___ L___ Open Space Footagc Y6 (Lot meum�vomooupaved � [ [ �� �� �0� F ��� f-------- f-------- � . parking) parking) r-- � — r—_ # of Parking Spaces L__ �-- L___J Fill: � - --------------� '-------� (volume Location) L - A. Has a Spe 0 DON'T KNOW da(Permit/Variance/Finding NO �_� �� YES �_� �� |F YES, date issued� | IF YES: VVasthe permit recorded at the Registry o[Deeds? NO 0 } DON'T �� _� IF YES: enter Book | | Page; | and/or Document #1 | ,������������ • B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW �~� YES v�� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained �~ «�� ne� Obta�d »�� Date ! exist �� L | ��� ' ' _____�__--__| �� C. Do any signs e�tontheprnperty7 YES «_� NO �N� __________________ ___________ _____ __ IF YES, describe size, type and location: \ ! � � ������������������������������������� D. Anethereanyproposedchangestooradditinnsofsignsintend 0 y� YES NO • _ ------ YES, |FYES describe size, type and ' location: ' L__-___'_____'_____'__-_____-_-_______-_______! E. Will the construction activity disturb ring, grading on, or filling) over 1 acre or is it part of a common plan that will �� dio�urbovor1ucne? YES � NO ��� �� IF YES, then a Northampton Storm Water Management Permit from the DPW is required RECEIVED D use only ; R City of Northampton Status of P erml t� �� � � Building Department Curb Cit -;4:',-;")..,, r �'a,'t ' � t eam. x. `4b" a � 'a. ,«�+� v4 � ' JAN - 2.01Z 212 Main Street Sewer / Real ab i s y��. <, „ Room 100 Water/Well Availa�Ihty =Ga .,.r<< ,s.r� +t,,. K��, -- OF WRONG INSPEC O1 • rthampton, MA 01060 Two Sets of Struc uial Plans NORTHAMPTON MA - 587 -1240 Fax 413- 587 -1272 Plot/Site Flans .�° " zh,Ut °? r i a . ...,.,0 0 , ")„ . ...;#4 4 ,,,.. ;' i * ° , }� s, ,,,k,01.„"'„,1, , a . 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 q iacijSi Lavt Map Lot Unit F i o i^e rice M A L"' 1 n 6 2 Zone Over District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: %Tack Horncr & Ronalc Skitin `f6 La(Q s1 ;,o Ln. rlare 1 MA 01062 Name (Print) Current Mailing A dre 61 3) 524 s /03 c . e ec J. A 3re_e-►rtent p .2k) P _ Telephone Signature -' 2.2 Authorized pp Agent: -' II '1 , S }. a )\ 13atrfort & Taccb A S .ScC l'ejes ) LN C. 70 cic# -5,,,(+1, S't.r.e.e1 �cr / M/l Ol060 Name (Pri . Current Mailing Address: Signature / Telephone SECTION 3 - ESTIMA F �' CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4 21 1 ;C C o (a) Building Permit Fee / 2. Electrical t 3 2. 3 o, 00 (b) Estimated Total Cost of Construction from (6) 3. Plumbing 1000 0 0 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection j 1 6. Total = (1 + 2 + 3 + 4 + 5) .1; 2 , 2B O Check Number /1 ,> b 5T/ ` 6g- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date p File # BP- 2012 -0624 APPLICANT /CONTACT PERSON BARRON & JACOBS ADDRESS/PHONE 70 OLD SOUTH ST NORTHAMPTON (413) 586 -8998 PROPERTY LOCATION 46 LADYSLIPPER LN MAP 35 PARCEL 224 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ``�$d 4-j0-4-S1 Fee Paid �(O Typeof Construction: REMODEL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 030739 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOATION 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 -lay Signature of : il. ing • fficial 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. 46 LADYSLIPPER LN BP- 2012 -0624 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 224 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0624 Project # JS- 2012- 001074 Est. Cost: $86280.00 Fee: $517.68 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BARRON & JACOBS 030739 Lot Size(sq. ft.): 91040.40 Owner: HORNOR JOHN W Zoning: SR(100) //WSP II Applicant: BARRON & JACOBS AT: 46 LADYSLIPPER LN Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586 - 8998 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:1/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN 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 1/5/2012 0:00:00 $517.68 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner