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29-035 h41/ 00) • ,. fi `,,, 1 ._ h 11 I i g ■ \\ �`± f 'F fi 4 s 1 ( \ \: \\\\ \ \ , 1 , Jt t e : F, i u L I t I . b j 1► t I t . t 1 1... .m 1 41 1�f ' I ■ ARBITRATION: THE CONTRACT AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THE CONTRACTOR HAS A DISUPUTE CONCERNING THIS CONTRACT MAY SUBMIT SUCH DISPUTE ._ A.._P.RIVATE. ARBITRATION - SERVICE-W11 Ctr 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. KEI T ER 1 DERS HOMEOWNER y 06 - 2 r-o Byi tt eiter, i s 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 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. 5 ACORD CERTIFICATE OF LIABILITY INSURANCE o6ioii2 9 PRODUCER (413) 586 -0111 FAX (413) 586 -6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnel 1 Ins . Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North Kin Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR King ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # • INSURED Scott Keiter INSURER A: Travelers Companies, Inc. DBA: Keiter Builders INSURER B: 351 Pleasant Street Ste 147 INSURER C: Northampton, MA 01060 INSURER D: 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 POLICY EFFECTIVE POLICY EXPIRATION LTR INSRI TYPE OF INSURANCE POLICY NUMBER DATE (MM /f)D/YY) DATF (MM /DDIYY) LIMITS GENERAL LIABILITY APP /BOP 06/01/2009 06/01/2010 EACH OCCURRENCE _ $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 300 000 PREMISES (Fa (IN I CLAIMS MADE I X OCCUR MED EXP (Any 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 7 POLICY n E Ii LOC 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 $ 7 OCCUR CLAIMS MADE AGGREGATE _$ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 1 TORY t IM TS I O F R EMPLOYERS' LIABILITY E.L. EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, cribnder SPECIAL des PRO VI below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS 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 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. -- For Informational Purposes --- AUTHORIZED REPRESENTATIVE Cynthia Henderson /CINDY ACORD 25 (2001/08) © ACORD CORPORATION 1988 • EY.e - P , 4 - /4 1-it_ Board of Building Regulat ons and Standards I_(= One Ashburton Place Room 1301 = Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 163295 Type: DBA Expiration: 6/1/2011 Tr# 284719 KEITER BUILDERS SCOTT KEITHER 51 B HATFIELD ST _ NORTHAMPTON, MA 01060 — Update Address and return card. Mark reason for change. DPS -CA1 0 40M- 08/08- DBSLIFORMCA108212008 ❑ Address j Renewal Employment Lost Card �P1 7e -6anvownwea/Vi ol,/gzaaackeaee Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards (__ Registration 163295 One Ashburton Place Rm 1301 EXpiration: 6/1/2011 Tr# 284719 Boston, Ma. 02108 Type: DBA KEITER BUILDERS SCOTT KEITHER /1 51 B HATFIELD ST • 4/ 01 - _- - - - - -------.------- - NORTHAMPTON, MA 01060 Administrator of valid without signature • HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations The inspection process requires that the building depa tment be called to inspect work at various stages, which include foundation /footings (before backfill), .. sonotute holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections_ can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper ------- - --pei ts-in- conjunction. "to - the- buildingpermmitissued,_ that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. __mate Address of work _ + location s The Commonwealth of Massachusetts Department of Industrial Accidents 1 s � " 1 � ... �..� - Office of Investigations . = i . = y 600 Washington Street Boston, MA 02111 „� ' www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required): i 1. D I am a employer with 4.. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have lured the sub- contractors 2 I an a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have. ns. r^Allo }lees These sub - contractors have. 8. ❑ Demoliion I working or me in any capacity. employees and have workers' 8 Y P tY 9. 0 Building addition [No workers' comp. insurance c- P.- :assurance.$ required:] 5. [] We are a corporation and its 10.[] Electrical repairs or additions 3. I am a emeowaerfie ail wok � cershave xezcise their 11 -.0- Plumbing repairs or additions myself [No workers' comp. insurance right of exemption per MGL 12.1 Roof repairs rance required] t c. 152, §1(4), and we have no employees. n c workers' 13 Other AA 4 NILE. 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. 1 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 ofMGL 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. 15e advised that a copy of thiw statement may be forwarded to the Office of Investigations of th 41 . ' for ins se ice coverage verification. _ I do hereby certi der a/c and penalties ofperjury : that the information provzded_above is true - and_correc. ___ __ Siznature: Date: 6 $ 0 31 erT q Phone #: 4 L ( . — l 03c I IF O use only. Do riot' write in this area, to be cWitedby city or town official City or Town: Pernait/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town CIerk 4. EIectrical Is . ector 5. Plumbing Ins. ector _ _ 6.Other Contact Person: Phone #: - SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : JCCIr(° V€ %TSP., ( 0 2- License Number 51 I�A 4 \t L ' Sz ) Tt% 1& Pl P la�yo' 2 o I 'z Address / / Expirati Date Signatu . / Telephone 3 .32- _ , _ T 57.0 � > ti, r'. "; x 9.:; Registered uHomeiriiprovernent:Contraetor .p ,., , ., ,. .. r, , . Not Applicable ❑ Rvi Lbe-r25 / 63 Z9S Company Name Registration Number 3S >r- ��sANT S S t. l�,E r 51 7 (o t /2011 Address boa. A- Expiration Y "� t� �r Telephone /a3 =3b "05.7 SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J 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 N F INP4p4Afee fol The_current_exemption for "homeowners" was extended to include Owner 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 o ampton Orin a e r . • ' • .1 - • ® eneral- Laws - Annotated. Homeowner Signature l ` 1' wb • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House : [ " 'Adtlitioh ❑ Replacement Windows Itdraiio"tt(s) - u r ' ' Roofing ❑ Or Doors E Accessory Bldg'. Det[toUtion Lam •' • Neta`sfbbEs ", [!�!I}4/! rADicks. [[] t Sl mil] < Other (0] J Brief Description of Proposed j >~ ' Work: b.2Ee.Att New - cvt- EA...Att- ■1 - 1-e_ 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.. houseTAII r�ition ci'eaustincl tiousrnu comet • t$ ff rr ± '• A a. Use of building : One.Fanyly Two Family... . . , . Ot�mar ° 2 • • *.• h , 4 • 7 - • r • b. Number of rooms in each family unit: Number of Bathrooms'( ■ *. t.'�t r ay i. \ J1:4, k + r - 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? .. 4•CrJe 4 �. y t 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 , 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 , 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 Name Signature of Owner /Agent Date o - TrISc1 E l) 0_,ce1/4/772AC- III NIA- ,... 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 . • 0' • Building Height ------ ----,-• ,, ___ , • Bldg. Square Footage 1 7 7-- „t— _ t , , ___,, ' .. L....,_1 Open Space Footage , % , (Lot area minus bldg & paved , ; parking) # of Parking Spaces • ' 0 - " - • :I • .4 ., * _ _ t • t t Fill: , (volume & Locktion) . . ........,i ,____ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? 110,147.KNOW•40 YES • ' - -. 4 - 4 6 . .. tjp e • I p 66, ofr .766.. , *,., . , i ... ( .1 1 . 1 . • . 6 . 4 4 i `■ 4. ", ‘ . IF YES, date issued: I ,.... .4% IF YES: Was the pe itco;ded ettleitegistry of Deeds? NO 0 DONT KNOW YES 0 t 3 IF YES: enter Book : I Page' , and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 - ... . . k IF YES, has a permit been or need to be obtained from the Conservatibn Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the preperty? YES 0 NO 0 IF YES, describe size, type and location: - '-------- — D. — ATF ffiii iig ? 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , A w .. ` ; `, ` City of Northampton t of - 04 _ "" ` c - , �, , Building Department cu �� ;� �z ( - -.- 7 �� `� �.,- ' ' . 212 Main Street s' e 8, ,119#0,14 �¢''� a _,,, Room 100 "a vG -' 3 \ No am ton MA 01060 0 x r f* std x . :0 P » ets® f ,r ' P 5 413 -5 7 -1240 Fax 413 - 587 -1272 iti t e=7atls` . � t "9i��' e- t \ 4?Pt.ICAT -IQN C ONSTRUCT, 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 ` v 1 /ONCGQ 1.11► D4J Leg Map Lot Unit fj._pQ6NaC� NAP Zone `' Overlay District Elrri.St. District CB District SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone 1/ Cgi/f - CO Signature 7 2.2 Authorized I� L-rr t: I 1 K R e& S / 8 opprieLD / ►r �I' •ie r/ TAn1 Name (Print) Current Mailing Address: - a ? -32c 903 Signature Telephone SECTION - ESTIMAi'ED COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /, 2 S-O 'lay Building Permit Fee • 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 +3 +4 +5) Check Number &0 This Section For Official Use Only Building Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings- -- - Date r File # BP- 2010 -0125 APPLICANT /CONTACT PERSON Keifer Scott ADDRESS/PHONE 51B Hatfield Street NORTHAMPTON (413) 320 -9035 0 PROPERTY LOCATION 48 PIONEER KNOLLS MAP 29 PARCEL 035 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out `� `,� --_ Fee Paid (p 3 Typeof Construction: REPLACE FIREPLACE MANTLE 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demolition Delay , Z"D Signature of Building Offi al 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. 48 PIONEER KNOLLS ° . BP-2010-0125 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block.: 29 - 035 CITY OF NORTHAMPTON 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 -0125 Project # JS- 2010- 000148 Est. Cost: $1250.00 . Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 11979.00 Owner: LOVELESS JOAN S Zoning: URA(100)//WSP Applicant: Keifer Scott Applicant Address: Phone: Insurance: 51B Hatfield Street (413) 320 -9035 0 NORTHAMPTONMA01060 ISSUED ON:8/5/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE FIREPLACE MANTLE 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: 0 K .F' v q •Q. _1,4 THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IONS. Certificate of Occupancy signature: Ie FeeType: Date Paid: Amount: Building 8/5/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo