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02-023
- - CERTIFICATE OF LIABILITY INSURANCE I v""tM1.1'UU'r7VT) 06/01/2012 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 BY 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). PRODUCER CONTACT NAME: Webber & Grinnell Ins. Agency, Inc. (a"rc°,No.E c): 413.586 0111 ,FAX No):413_.586.6481 8 North King Street ADDRESS: Northampton, MA 01060 PRODUCER 00021099 CUSTOMER ID a: INSURERIS)AFFORDING COVERAGE NAIC 0 INSURED INSURERA: Travelers Casualty of America Keiter Builders, Inc. INSURERS: Travelers Indenwt. Co. CT 25682 51A Hatfield Street INSURER C: Northampton, MA 01060 INSURERD: INSURER E- I INSURER F: l COVERAGES CERTIFICATE NUMBER: Master Exp 06/13 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY EXP I LIMITS X FI L i' (MM01/2013 1 GENERAL LIABILITY ISUBRI POLICY EFF , LTR INSR 1 UB I POLICY NUMBER _ { INSR (MMroonvrY) ',.06!01/2013 f I if 1,000,000 I I6806319N661ACJ12i 06101!2012' 300,000 X _._u- --n .` s 5,000 A c E F r 1,000,000 :I,_F_L ___,E r 2,000,000 I-' 2,000 000 ` I AUTOMOBILE LIABILITY - F'''I=, - _•'s'l f • , UMBRELLA LIAB --- - '.. _,-r'.,_. E';?r- I r EXCESS LIAB _ r .1c I I ' _ WORKERS COMPENSATION IEUB2A56578212.0611 112012 1 06/1112013 1 I T u I , AND EMPLOYERS'LIABILITY YIN 1 `. --_-- ra rF RIET F 1-.,T,. L,_,�T:'= err ,_I I Eli 100,000 B ,IErrrc_r, DIET j NIA , E (Mandatory in NH) I 1 F t I F l`1 IF F;I' 100,000 I r.. 1t= r 500,000 I L'E--r-,—, _iii,- r Ct' 11 .pl.p; E L ,p.,(_ C I•I -a' �, III DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES{Attach AC ORD 101.Additional Remarks Schedule.if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE rte.: - For Information Only *-••-- Cynthia Henderson, CISR/CINDY ©1988-2009 ACORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 c4; 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): 41?�y\ ArC. Address: S 1 h 'PA- lEq) Sr City/State/Zip: {V 04.--nikvisveki, Iltt blow Phone#: 913 S8'(c • o ° AI•e you an employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): 1 am a employer with 3 ❑ g employees(full and/or 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. employees and have workers' g Y P h 9. ❑Building addition [No workers' comp. insurance comp.insurance.: 10.0 Electrical repairs or additions required.] 5. ❑ We are a corporation and its 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 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13621..0ther -61ocAcemeArr comp.insurance required.] I■ J I "1-ROWS *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: hez. et-e-11.3 y,150(I ANCE — Policy#or Self-ins.Lic.#: T E v B 2_A$bS 76Z1 Z Expiration Date: !c, • (1 . 2. b 1 3 Job Site Address: ‘O07— K1• 'CAA-MS City/State/Zip: c—onE—N cc.) MA O bb 2— Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ',i;under t ,' ands;enalties of perjury that the information provided above is true and correct. Si a ature:. s' - rs. Pc *Date: • Phone#: ` /,3• S-8 b lQ d o 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#: 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. By signing this Agreement,you acknowledge that you have received a complete and original signed copy of the entire Agreement and attached Exhibits. Keiter Builders, Inc. 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 A T T O R NE Y BEFORE SIGNING. KEI TER BUILDERS,INC. HOMEOWNER i I 3 '3o • 1 1 N-C'L ' ]' ! 1 i I '� Scott Keiter,its president Date I Date Y� P Date 5 I You and Keiter Builders, Inc. 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 thirty (30) days due to your failure to make a payment on time, or make Keiter Builders, Inc. feel insecure, or if you should commit a material breach of any of your responsibilities or obligations under this Agreement, then Keiter Builders, Inc. 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 Keiter Builders, Inc. may have incurred or might incur in good faith in connections with this Agreement,as well as receiving payment for Keiter Builders, Inc. 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: Keiter Builders, Inc. will grant you, as part of the Total Price, a Limited Warranty, a copy of which is attached to this Agreement. Keiter Builders, Inc. 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 'THIN; CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A 4 failure to pay on time, or to make Keiter Builders, Inc. 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. KEITER BUILDERS, INC. MAY NOT REQUIRE YOU TO PAY PART OR ALL OF THE BALANCE NOT YET DUE UNDER THIS AGREEMENT BECAUSE KEITER BUILDERS, INC. DEEMS ITSELF TO BE INSECURE. HOWEVER,IF KEITER BUILDERS, INC. DEEMS ITSELF TO BE INSECURE, IT MAY REQUIRE 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 KEITER BUILDERS,INC. SIGNATURE FOR ANY WITHDRAWAL. SUBCONTRACTORS: Keiter Builders,Inc. intends to hire the following subcontractors to assist in the work: Name NA These may not be all the subcontractors that may be hired, and Keiter Builders, Inc. may decide not to hire any one or all of the above subcontractors,which decision shall be at Keiter Builders, Inc. sole discretion. If you ask any subcontractor to make any changes or substitute materials without first obtaining Keiter Builders, Inc. 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 Keiter Builders, Inc. the additional cost any subcontractor charges Keiter Builders, Inc. for such changes and substitutions,and for any extra work and material related to your request,plus Fifty (50%)percent. INSURANCE: Keiter Builders, Inc. 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 Keiter Builders,Inc. 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, 3 of conservation commissions,are required to be obtained before Keiter Builders,Inc. can obtain their permits, it is your obligation to satisfy such requirements and you shall meet those requirements at your cost. STARTING AND ENDING DATES: Keiter Builders, Inc. will apply for the permits within 30 day(s) of signing this Agreement or your satisfying any conditions required to be met prior to the permits being used, whichever date is later. Keiter Builders, Inc. will start work within 30 day(s) of obtaining the necessary permits and expects to have the work substantially completed within 10 day(s)of starting. If Keiter Builders, Inc. is delayed at any time, in the progress of completing the work, due to acts of God, war, civil commotion, 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 Keiter Builders, Inc. may reasonably extend the date for substantial completion. If the work is not substantially complete by the ending date, as extended, Keiter Builders, Inc. 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,Keiter Builders, Inc. 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 Ten Thousand, Eight Hundred and Seventeen Dollars and Thirty Three Cents ($10,817.33) DOLLARS. Payments against work completed and materials delivered will be made within 2 days from when Keiter Builders, Inc. notifies you that they have reached different completion stages. Payments will be made in the amounts as set forth in the attached payment schedule. 60%of window cost due with signed contract ($4,261.33) 40% of window cost+ 1/3 labor& misc.material due prior to initiating work ($4,079.26) Final payment due at Substantial Completion. ($2,476.74) 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 whichever is less. In the event that Keiter Builders, Inc. incurs 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 Keiter Builders, Inc. may immediately stop work. Keiter Builders, Inc. may choose to not start work again until you are current with the payments and Keiter Builders, Inc. feels secure in obtaining the remaining payments. If there is any stoppage in work due to your 2 t CONSTRUCTION AGREEMENT Keiter Builders, Inc., of Northampton, MA whose Federal Tax Identification Number is 27-2518846, Contractor's Registration Number 163295 (Exp. 06-01-2013), and License #102457 (Exp. 06-20-2014), is entering into this Agreement with you Yvonne Freccero of 602 North Farms Rd.,Florence,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: Keiter Builders, Inc. will perform the work set forth in the attached Scope of Work on your home, or the property located at 602 North Farms Rd., Florence,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. Keiter Builders, Inc. reserves the right to make minor changes in any plans and to substitute materials of equal or better quality. Should Keiter Builders, Inc. 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 Keiter Builders, Inc. 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, Keiter Builders, Inc., or subcontractors hired by Keiter Builders, Inc., will obtain, on your behalf,the following permits(if required): xx Building Permit Electrical Permit Smoke Certificate Plumbing Permit Demolition Permit Certificate of Occupancy IT IS THE OBLIGATION OF KEITER BUILDERS, INC. TO OBTAIN THESE PERMITS AS YOUR AGENT. IN THE EVENT THAT KEITER BUILDERS,INC. DOES NOT OBTAIN THESE PERMITS, AND YOU OBTAIN THEM, OR IF KEITER BUILDERS, INC. IS NOT REGISTERED WITH THE BOARD OF BUILDING REGULATIONS, YOU WILL NOT BE ENTITLED TO OBTAIN ANY BENEFITS FROM 'IME GUARANTEE FUND ESTABLISHED UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 142A. Keiter Builders, Inc. obligation to obtain permits is limited to those permits directly related to performing the work Keiter Builders, Inc. agrees 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 r BUILDERS SCOPE OF WORK March 30,2013 CUSTOMER NAME: Yvonne Freccero ADDRESS: 602 North Farms Road,Florence,MA 01062 ESTIMATED START DATE: Spring,2013 ESTIMATED PROJECT RUN TIME: 3-Days ADMINISTRATION • Keiter Builders,Inc.will manage the following aspects of the project: o Building permit application o Standing all necessary inspections o Materials ordering and delivery o Site set-up and break-down o Certificate of Occupancy WINDOWS (Please see attached Andersen Quote#3883 for window specifications) This contract includes the following: • Permit application,fees,and inspections. • Installation of(13)Andersen window inserts. This includes removal/disposal of storm units, existing sash units,and misc. components,preparing the opening to accept new units,installation of new inserts,all caulking/weather sealing,and installation of new/existing interior stops,if necessary. • Please note that the following are not included in this contract: Any painting,nail hole filling, stain, polyurethane,or other finishes. PRICE FOR WINDOWS(Including Tax): $7,102.22 PRICE FOR PERMIT,MISCELLANEOUS MATERIALS,AND LAB OR: $3,715.11 TOTAL PRICE FOR LABOR AND MATERIAL $10,817.33 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: C-OT T K�I TER- I 0 2-11 551 License Number 51 I- ` E t-E,>.-D ST, KFOR-n-ktic-vvtioio lv-ai ocon G - 2 0 -tot�E Address Expiration Date 415. S& -8hoo Si ature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ k&f.Tan. (3u i C-DC7GS (c - i+ 7 S-1 Company Name Registration Number St Pr t-t* i tt Sr. 7 D ti-n-i-Pr17)R3 MA y• 29. Address c n p Expiration Date Telephone x/13•SgG -P 4 • c7 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 10835.1. 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 ❑ Replacemen W ndows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs f] Decks [❑ Siding CU Other[CI Brief Description of Proposed Work: i n'al( -io-v∎ oV 13 - tna-e v.J c W i✓ .b oz, Alteration of existing bedroom Yes No Adding new bedroom Yes ?< No Attached Narrative Renovating unfinished basement Yes X 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 b- ow finished grade k. Will building conform to the c•riding and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION Ta-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. P(-4---A Se, SEE a'rMC-1 t• SIG/ -b 00/1/77L/A-C — Signature of Owner Date I, V CO"C"A . trerz rAA tor)-ee I kic • ,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. Sign-d under he pains and penalties of perjury. 11.1//Ir#61iik Co-rr- rrt-g- Print ame X7rA S t c�l�--JCt IL I1 S 5• 1 - Sig ure of 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 of YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW Of YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO p IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex ..vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YEE O NO ∎. IF YES,then a Northampton Storm Water Management Permit from the DPW is required. --- , Department use only "°° °- City of Northampton Status of Permit: B Ilding Department Curb Cut/Driveway Permit F---- toy-- 2U i 3 12 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEPT.OF BUILDING INSPECTION Orr ampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON �'iC 413- 7-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ae This section to be completed by office ,p2 �pv-4 .FaVWS Poact Map Lot Unit Pt Of-PAC--e— M A- °t 0 fo Z- Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Y(.1 4 AI .c.4 .L&. ,o (Q d L N r(U &S K . , �^ --0A..EA/c6) MA Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Anent: 1;6--(1Ee_ butL-DE--9_ , It-c__. Sl A Rai--C--;Ac �-i- 1\64-(n 4 Name Print) Current Mailing Address: 0,-„_---. ii.t.S,ck.. 413--5S,(c-- Gov Sig Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i 0, g1-1 33 (a)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) lo , $t'i • 3 3 _ Check Number 69n 0-3, _...... This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date a 602 NORTH FARMS RD BP-2013-1063 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:02-023 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2013-1063 Project# JS-2013-001758 Est. Cost: $10817.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq.ft.): 81282.96 Owner: FRECCERO YVONNE Zoning:RR(100)/WSP(100)/WP(71)/ Applicant: SCOTT KEITER AT: 602 NORTH FARMS RD Applicant Address: Phone: Insurance: 51A HATFIELD ST (413) 320-9035 WC N O RTHAM PTO N MA01060 ISSUED ON:5/8/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 13 REPLACEMENT WINDOWS 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 5/8/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner