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24C-101 , i \ I 1 1 \ i 4 --- ,2.- ■ . .-----------__ ----. -- k f . , , (s , i . S- . , . I . I , . . ! I . 1 . I , , I .,------.., . = (--,-- : i I , 1 , \J , . i \ , 1 : 1 . 1 , i \ ' . . . . . , : d . . , c) . . . . . . . , . . . .. ...._ i -s) . ! --- r t t i . i 1 . ..------------ ---4. vyv rsAtu&v1-0-0.-1)()C\fi \ _110SVSSIAW L . . Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self - insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617 -727 -4900 ext 406 or 1 -877- MASSAFE Fax # 617 -727 -7749 Revised 4-24-07 www.mass.govidia '- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 a www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): S e cTT kC i rE Address: cI g I k T ElEL-t1 SV City /State /Zip: t 0-yA - r - vN.) )1/1 1 p 1O(oc) Phone #: V) 3 - 3 Z v - qa ; s Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and /or part-time).* have hired the sub contractors 6. ❑ New construction 2.K I am a sole proprietor or partner- listed on the attached sheet. 7. TIORemodeling 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.t ❑ required.] 5. We are a corporation and its 10.0 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 12.0 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. tl{o meowners 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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/• 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 da against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the •IA' for insurance coverage verification. I do hereby certif, t der the pat a I p nalties of perjury that the information provided above is true and correct. Signature: / Date: O ' 1 S f O Phone #: f—1 l 3 - 32d - ?0 -3 3 --- v 3.) 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 #: CONTRACTOR'S LIMITED WARRANTY KEITER BUILDERS 51B Hatfield St. Northampton, MA 01060 Phone: 413 - 320 -9035 Fax: 413 - 586 -1890 The contractor signatory below Scott Keiter ( "Contractor ") hereby guarantees Shauneen Kroll "Owner ") that the construction performed on that certain structure located at 93 Massasoit Street, Northampton, MA to be free from defects in material and workmanship for a period of one (1) year from the date of commencement of use, substantial completion or date of notice of completion, whichever is the first to occur: This Standard Limited Warranty applies and is limited as follows: 1. To the property only as long as it remains in the possession of the original owner named above. 2. To the construction work that has not been subject to accident, misuse or abuse. 3. To the construction work that has not been modified, altered, defaced, or had repairs made or attempted by others. 4. That Contractor be immediately notified in writing within ten (10) days of first knowledge of defect by owner or his agent. 5. That Contractor shall be given first opportunity to make any repairs, replacements or corrections to the defective construction at no cost to owner within a reasonable period of time. 6. Under no circumstances shall Contractor be liable by virtue of this warranty or otherwise for damage to any person or property whatsoever for any special, indirect, secondary or consequential damages of any nature however arising out of the use or inability to use because of the construction defect. / ic ,or j _ . _ 403- /2.-/0 - na ure Date ____ ICEFFEI BUILDERS 51E3 Hatfield Street •Northampton•MA•01060•Phone: 413 - 320- 9035•Fax: 413 - 586- 1890•keiterbuilders.com SCOPE OF WORK March 12, 2010 CUSTOMER NAME: Shauneen Kroll ADDRESS: 93 Massasoit Street Northampton, MA 01060 SCOPE OF WORK: • Building Permit and Inspections • Demolition & debris removal (Existing deck planks and trim @ wall) • Review /reinforce existing framing (Please see note below) • Repair /remove rot on (3) post bottoms • Install new Douglas Fir tongue and groove (1 x 4) flooring • Re- connect all loose railings to posts • Install new fascia @ side stair location • Re -set and plumb all porch posts • Install new trim against house Waste • A sincere effort will be made by all Keiter Builders employees /sub contractors to minimize waste during the construction project • Any recyclable material will be separated from general waste • All waste will be contained in a dumpster and/or taken from site in a timely manner • The jobsite will be kept clean and tidy at all times during the project Warranty • Please see the attached document "Contractors Warranty" Permits and Inspections • All applicable permits will be handled by Keiter Builders • All building inspections will be scheduled by Keiter Builders TOTAL LABOR and MATERIAL: $6,100 Note: This estimate includes minor framing /repair only. If additional work is required, the homeowner will be notified NOT SEPARATELY SIGNED BY THE PARTIES. THE RIGHT TO INITIATE ALTERNATIVE DISPUTE RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THIS AGREEMENT. MISCELLANEOUS: This agreement is a Massachusetts contract, contains the entire agreement between us, any representations or warranties not expressly contained in it are not a part of the Agreement, and it is binding upon our heirs, executors, successors and assigns. This Agreement may be modified only by an instrument in writing signed by both of us. This agreement is subject to and is intended to comply with the provisions of Chapter 142A of the Massachusetts General Laws and its corresponding regulations. RIGHT TO CANCEL CONTRACT: YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO BY FORWARDING YOUR INTENT TO CANCEL IN WRITING BY ORDINARY MAIL POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. By signing this Agreement, you acknowledge that you have received a complete and original signed copy of the entire Agreement and attached Exhibits. I may not start work until after this Agreement has been signed. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS IS A LEGALLY BINDING AGREEMENT. IF THERE ARE ANY PROVISIONS WHICH YOU DO NOT UNDERSTAND, YOU SHOULD CONSULT WITH AN ATTORNEY B E FO R E SIGNING. KEITER BU DERS HOMEOWNER I / '%, // / 403 — /2--/c 7 by, tt ' eite s owner Date Date Date 5 obligations under this Agreement, then I may, upon giving you seven (7) days written notice, terminate this Agreement and recover from you payment for all work performed; for any unpaid costs of and fees for the work; for any liability, obligations, damages, commitments, and/or claims that I may have incurred or might incur in good faith in connections with this Agreement, as well as receiving payment for my attorney's and legal fees and all lost anticipated gross profits on the work not performed as of the date of the termination. NOTICE: -- - - -- -- - - - - - -- — Notice will be deemed if delivered in hand or if sent by certified mail, return receipt requested, to the address listed on the front page of this Agreement. WARRANTIES: I will grant you, as part of the Total Price, a Limited Warranty, a copy of which is attached to this Agreement. I will use materials that are currently acceptable for their intended use in performing work. You should be aware that it may be determined that some of these materials may cause health problems. If there are any materials that you do not want used in the work, list them on the attached Scope of Work form. EXHIBITS: The following Exhibits have been attached to this Agreement: Scope of Work Limited Warranty ARBITRATION: THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THE CONTRACTOR HAS A DISUPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVIED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A. KEITER BU ERS HOMEOWNER o2 a 3 42 JO,` 3 / / v By Sc Keiter, its owner Date Date Date NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS 4 I MAY NOT REQUIRE YOU TO PAY PART OR ALL OF THE BALANCE NOT YET DUE UNDER THIS AGREEMENT BECAUSE I DEEM MYSELF TO BE INSECURE. HOWEVER, IF I DEEM MYSELF TO BE INSECURE, I MAY REQUIRE AS A PREREQUISITE TO CONTINUING ANY WORK THAT THE BALANCE OF FUNDS DUE UNDER THIS AGREEMENT, WHICH ARE IN YOUR POSSESSION, SHALL BE PLACED IN A JOINT EXCROW ACCOUNT REQUIRING BOTH YOURS AND MY SIGNATURE FOR ANY WITHDRAWAL. SUBCONTRACTORS: I intend to hire the following subcontractors to assist me in the work: Name N/A These may not be all the subcontractors that I may hire, and I may decide not to hire any one or all of the above subcontractors, which decision shall be at my sole discretion. If you ask any subcontractor to make any changes or substitute materials without first obtaining my written agreement, these changes may adversely affect another part of the work that you are not aware of any may create additional delays and costs. If you make such changes or substitutions, you will pay me the additional cost any subcontractor charges me for such changes and substitutions, and for any extra work and material related to your request, plus Fifty (50 %) percent. INSURANCE: I shall purchase and maintain liability insurance for protection of all claims under workman compensation acts and other employee benefit acts, claims for damages because of bodily injury, including death, and from claims for damages, other than to the work itself, to the property which may arise out of or result from my operations under this Agreement. You shall purchase and maintain property insurance in a form acceptable to me upon the entire work and materials for the full cost of replacement as of the time of loss. The insurance shall insure against the loss from perils of fire, extended coverage and shall include "all risk" insurance for physical loss of damage, including without duplication of coverage, at least theft, vandalism, malicious mischief, transit, collapse, flood, earthquake, testing and damage resulting from defective design, workmanship or material. You will increase the limit of coverage, if necessary, to reflect the estimated replacement cost. You will be responsible for any co- insurance penalties or deductibles. If the work covers an addition to or is adjacent to an existing building, You and I agree to waive all rights against each other for damages caused by fire or other perils to the extent covered by insurance. RIGHT TO TERMINATE CONTRACT: If the work is stopped or delayed, either in whole or substantial part, for a period of thirty (30) days under an order of any court or other public authority having jurisdiction, or as a result of an act of government and due to your fault or negligence, or as a result of an act within your control; or if the work shall be stopped or delayed either in whole or substantial part, for a period of theirty (30) days due to your failure to make a payment on time, or make me feel insecure, or if you should commit a material breach of any of your responsibilities or 3 STARTING AND ENDING DATES: I will apply for the permits within 7 day(s) of our signing this Agreement or your satisfying any conditions required to be met prior to the permits being used, whichever date is later. I will start work within 30 day(s) of obtaining the necessary permits and I expect to have the work substantially completed within 10 day (s) of starting. If I am delayed __at_any_time,in the progress_ of completing the work,_due to acts of God, war.,civilcommotion, accident, government regulations or policies, any act or neglect of yours, or by any separate contractor, or by change orders, or by labor disputes, fire, delay in transportation, unavailability of materials, adverse weather conditions, unavoidable casualties, difficulty in obtaining fuel, electricity, services or supplies from the sources from which they are normally obtained, or other causes reasonably beyond my control, then I may reasonably extend the date for substantial completion. If the work is not substantially complete by the ending date, as extended, I will not be liable to you for any incidental or consequential damages you may incur due to such delay. If you are supplying any materials or equipment to be used in the work, you shall have such materials and equipment delivered to the work site not less than 5 days before they are needed for the work. If they are not delivered on a timely basis, I will not be able to schedule work dependent upon them and the date of substantial completion will be extended due to such delay. TOTAL PRICE AND PAYMENT SCHEDULE: The total price for performing the work and supplying the materials under this Agreement is one thousand, two hundred and fifty ($6,100) DOLLARS. Payments against work completed and materials delivered will be made within 2 days from when I tell you that I have reached different completion stages. Payments will be made in the amounts as set forth below. % of Total Price made prior to work being started ($3,050) '/z of Total Price made upon substantial completion of work ($3,050) All sums not paid before substantial completion of the work will be due and payable upon substantial completion. Payments due and unpaid under this Agreement shall bear interest from the date payment is due at the annual rate of Eighteen (18 %) percent or at the maximum legal rate which ever is less. In the event that I incur costs or expenses in collecting any payments due and unpaid under this Agreement, you shall pay such costs and expenses including reasonable attorney's fees. If you fail to make any payments when they are due, then I may immediately stop work. I may choose to not start work again until you are current with the payments and I feel secure in obtaining the remaining payments. If there is any stoppage in work due to your failure to pay on time, or to make me feel insecure that the remaining payments will be made, such delay shall automatically extend the date of substantial completion. ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED THE GREATER OF ONE -THIRD OF THE TOTAL CONTRACT PRICE OR THE ACTUAL COST OF ANY MATERIAL OR EQUIPMENT WHICH HAS TO BE SPECIAL ORDERED OR CUSTOM MADE, WHICH MUST BE ORDERED IN ADVANCE OF THE COMMENCEMENT OF THE WORK, IN ORDER TO ASSURE THE PROJECT WILL PROCEED ON SCHEDULE. NO FINAL PAYMENT MAY BE DEMANDED UNTIL THE AGREEMENT IS COMPLETED TO THE SATISFACTION OF BOTH OF US. 2 CONSTRUCTION AGREEMENT I, Scott Keiter owner of Keiter Builders, of Northampton, MA whose Federal Tax Identification Number is 264 9629, C Registration Number I6329f - (Exp: - 0fi -1=20 H ) and-License-#10245-7-(Exp.-06-20- ____ - -- 2012), am entering into this Agreement with you Shauneen Kroll of 93 Massasoit St., Northampton, MA. ALL RESIDENTIAL CONTRACTORS AND SUBCONTRACTORS ARE REQUIRED TO BE REGISTERED WITH THE MASSACHUSETTS BOARD OF BUILDING REGULATIONS AND STANDARDS, UNLESS SPECIFICALLY EXEMPT FROM REGISTRATION. INQUIRIES CONCERNING REGISTRATION SHOULD BE DIRECTED TO: DIRECTOR, HOME IMPROVEMENT CONTRACTOR REGISTRATION, ONE ASHBURTON PLACE, ROOM 1301, BOSTON, MA 02018 (617) 727 -8598. SCOPE OF WORK: I will perform the work set forth in the attached Scope of Work on your home, or the property located at 93 Massasoit St., Northampton, MA. If you would like to change any work to be performed or materials used, we will have to make such changes through a Change Work Order, which may also change the total price and extend the date for completion. Change Orders will be handled on a time and material basis. I reserve the right to make minor changes in any plans and to substitute materials of equal or better quality. Should I encounter any unknown conditions below the surface of the ground, or concealed or unknown conditions in any existing structure, you will agree to make an equitable adjustment with me under a Change Work Order, which shall increase the total price and extend the date for substantial completion of the work. PERMITS: To perform this work, I, or subcontractors I hire, will obtain, on your behalf, the following permits (if required): x Building Permit Electrical Permit Smoke Certificate Plumbing Permit Demolition Permit Certificate of Occupancy IT IS MY OBLIGATION TO OBTAIN THESE PERMITS AS YOUR AGENT. IN THE EVENT THAT I DO NOT OBTAIN THESE PERMITS, AND YOU OBTAIN THEM, OR IF I AM NOT REGISTERED WITH THE BOARD OF BUILDING REGULATIONS, YOU WILL NOT BE ENTITLED TO OBTAIN ANY BENEFITS FROM THE GUARANTEE FUND ESTABLISHED UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 142A. My obligation to obtain permits is limited to those permits directly related to performing the work I agree to do. To the extent that other permits or governmental or regulatory agency approvals, such as, but not limited to, zone changes, variances, special permits, site plan approvals, or approvals of conservation commissions, are required to be obtained before I can obtain my permits, it is your obligation to satisfy such requirements and you shall meet those requirements at your cost. ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) TM 03/09/2010 PRODUCER 413. 586.0111 FAX 413. 586.6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnell Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8 North King Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton MA 01060 INSURERS AFFORDING COVERAGE NAIC # INSURED Scott Keiter INSURER A. Travelers Casualty of America DBA: Keiter Builders INSURERB WCAR- Liberty Mutual 51B Hatfield Street INSURERC Northampton, MA 01060 INSURERD 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. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION M! LIMITS LTR INSRC DATE (MDDTYYYY) DATE (MMIDDTYYYYJ GENERAL LIABILITY 6806319N661ACJ09 06/01/2009 06/01/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PR l o FED PREEMIMI E SES ( (Ea u occurrence) $ 300, 000 CLAIMS MADE X OCCUR MED EXP (My one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO - LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY 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 $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC231S376387010 03/05/2010 03/05/2011 WCSTATU- OTt AND EMPLOYERS' LIABILITY TORY LIMITS ER Y! N B AN PRO BO R EXCLUDEEXECUTIVE E.L. EACH ACCIDENT $ 100,000 (Mandatory In NH) YES E . DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E . DISEASE - POLICY LIMIT $ 500, 000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The Workers Compensation policy does not provide coverage for Scott Keiter. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 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 REPRESENTATIVES For Informational Purposes Only AUTHORIZED REPRESENTATIVE Cynthia Henderson /CINDY ', ACORD 25 (2009101) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 Not Applicable ❑ Name of License Holder : Corr Ye- i- 2 / d 2' f.S 7 A License Number SIR 4A-re e� sr. , AJoriT1+f . TON � 1510 (o 0 X0'.20 - �0/ L 11 Expiration Date 3.to - FO 3S' nature Telephone 9. Registered Home Improvement Contractor: p Not Applicable ❑ '9c�o r �CE i�'c --vim QA �(�, rem- ©c,i ems /G 3 2% Company Name Registration Number St g (4 1 ckL'0 10-7 kvrz } Tan► M 06-of- . a / / Address ) Expiration Date Telephone y / 3- 3Lo - 5' r 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 r!r 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) n Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition �: New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed [� Work: T EMo FiXI ST7IW POlaN becIC g QfiparcE QO7 Q6.? X41 Q Alteration of existing bedroom Yes No Adding new bedroom Yes 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 1 pLrch5 6 SEE , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date c o ;1 t TC , 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. co - rr - , T�- 11E Print Name Signature . • er /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 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 DONT KNOW 0 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 Q DONT KNOW ® 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 ® 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 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 City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit F LQ �0 212 Main Street Sewer /Septic Availability 1\r +'. �' Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 Fax 413 587 - 1272 Plot/Site 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 93 MA5S4So( STREET Map Lot Unit N° 2:T1- 1Aw , e1APr Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: SI+14 L.)N Ecry 4.0\—l— Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: C-c ■E PT'E-( Si 3 f-I ft E <b Sr /tJQ livarw q-ram! Name (P < Current Mailing Address: L(3 - 320 -3 0ls Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building A. / (a) Building Permit Fee l> 0 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) Check Number (C - 1 ' 55, OC) This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0801 APPLICANT /CONTACT PERSON SCOTT KEITER ADDRESS/PHONE 51B HATFIELD ST NORTHAMPTON (413) 320 -9035 PROPERTY LOCATION 93 MASSASOIT ST MAP 24C PARCEL 101 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /� Fee Paid /Q7 Typeof Construction: REPLACE PORCH DECKS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102457 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF NI ATION PRESENTED: IIVV 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 Demolition Delay 3/6/1 Signatur 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. f te r.. A T _ TH OF f Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0801 Project # JS- 2010- 001183 Est. Cost: $6000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 10890.00 Owner: KROLL MIKKEL C & SHAUNEEN S Zoning: URB(100)/ Applicant: SCOTT KEITER Al: 93 IVINSSASCA i ST Applicant Address: Phone: Insurance: 51B HATFIELD ST (413) 320 -9035 NORTHAMPTONMA01060 ISSUED ON ::3/16/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REPLACE PORCH DECKS 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: /IIY/' c o J -< Rough Frame: 3 / /7 1 16) tint Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: CI< 3 f 2 51(o THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy p-- signature: FeeType: Date Paid: Amount: Building 3/16/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 - 1272 Building Commissioner - Anthony Patillo