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31A-192 • CITY OF NORTHAMPTON Construction tebris Affidavit in accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work -covered,by-aBuilding Permit-shall be disposed of in a-properly licensed disposal facility, as defined by M.G.L. c..111 § 150A. • Address of Work: 75 W11344nyhm a ve_. The_debris_will be-transported by: ,CeA The debris will be received at: V gty ce, r/'l Signature of Permit Applicant bate • 2 0.13 • Building Permit Number: • • ' . AC®® DATE(MMIDD/YYYYj CERTIFICATE OF LIABILITY INSURANCE DATE 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,certan 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 Cynthia Henderson, CISR NAME: Y Webber & Grinnell I:ROIL ern. (413)586-0111 I FAlC,Nol:(413)586-6481 8 North King Street DREG:chenderson @webberandgrinnell-com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A:Travelers Companies, Inc. INSURED INSURER B:Citation 40274 Reiter Builders, Inc. INSURER C:Travelers Indemn. Co. CT 25682 51A Hatfield Street INSURERD: INSURER E: Northampton MA 01060 INSURER F COVERAGES CERTIFICATE NUMBERMaster Exp 12/13 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR !NSA WVD POLICY NUMBER (MDD/YYYYI (MM/DD/YYYY1 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 300,000 A I CLAIMS-MADE X OCCUR 680631956611342 6/1/2013 6/1/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE UMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 71 POLICY n mi. n LOC $ AUTOMOBILE UABILTY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED g AUTOS X SCHEDULED 12MNBCDRO7 12/21/201212/21/2013 BODILY INJURY(Per accident) $ AUTOS X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION I TORY LIMITS I I FR AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A 6/11/2013 6/11/2014 (Mandatory in NH) IEUB2A56578213 EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 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. ***** For Information Only ***** AUTHORIZED REPRESENTATIVE C Henderson, CISR/CIN Y""""A e'_A °ate ACORD 25(2010/05) @ 1988-2010 ACORD CORPORATION. All rights reserved. INSn95 call rincl nt The Af`f1Rrl nom"sand Inns ero ronictororl merle of A((Yuan 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. Owner understands and acknowledges that Keiter Builders, Inc. may use any photos taken during the course of work for promotional purposes. This may include, but is not limited to, the following: Website, newspapers, journals, magazines, posters, and flyers. 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 ATTORNEY BEFORE SIGNING. KEITER BUILDERS,INC. OWNER p a/3 • b g'cott Keiter,President Date Date //L( b„<() 4r4W. Dat- 6 The following Exhibits have been attached to this Agreement: Scope of Work Payment Schedule Limited Warranty ARBITRATION: THE CONTRACTOR AND THE OWNER 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 BUILDERS,INC. OWNER • / .. : , /3 . 13 C x- 15-13 By S 4 t Keiter,President Date Date Li 1E1 / 14411411111411 g'41-:"? 1 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. 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 DA'Z'E 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. 5 • ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED IILE 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. HOLD BACK FROM FINAL PAYMENT FOR PUNCH LIST WORK At time of making the final contract payment, Owner may hold back 100% of the value of all Punch List work. Owner and Contractor will place a fair and reasonable value on each Punch List item at time of Punch List walk-through with Owner. Contractor and Owner will then execute the Punch List form. This 100% hold back for Punch List work assures Owner that all Punch List work will be completed by Contractor in a timely manner. Payment for completed items is due and payable upon submittal of invoice for those completed items, even though the entire punch list may not be completed. Owner will have one (1) opportunity to create a Punch List with Contractor. SUBCONTRACTORS: Keiter Builders, Inc. intends to hire the following subcontractors to assist in the work: Name JOHN THOMAS,PLUMBING AND HEATING STEVE WILSON,ELECTRICIAN S.T. FLOOR COVERING D.D. PROFESSIONAL CLEANING SERVICE PAUL BROUILETTE,PAINTER PHOENIX ROOFING,LLC. 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. 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 60 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 Eighty Nine Thousand, Five Hundred and Four Dollars and Sixty Nine Cents ($89,504.69) 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. PLEASE SEE ATTACHED PAYMENT SCHEDULE 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 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. 2 CONSTRUCTION AGREEMENT Keiter Builders, Inc., of Northampton, MA whose Federal Tax Identification Number is 27-2518846, Contractor's Registration Number 175168 (Exp. 04-29-2015), and License #102457 (Exp. 06-20-2014), is entering into this Agreement with you Matthew&Barbara Pitoniak of 75 Washington Ave.,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: Keiter Builders, Inc. will perform the work set forth in the attached Scope of Work on your home, or the property located at 75 Washington Ave., 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. 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): x Building Permit x Electrical Permit Smoke Certificate x 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 THE 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 • All trim . o Sliding Glass Door. This includes: • A$4,000.00 allowance for a slider/French door with hardware • All labor and miscellaneous materials to install a slider I French Door o Custom Bench Seat. This includes: • A$300.00 material allowance and 12 man hours o Eliminate ironing board—patch drywall o Misc.Trim. This includes: • A$200.00 material allowance and 6 man hours • Cabinetry and Countertops o Please see attached r.k. Miles quote for all cabinet and countertop specifications. This contract includes a price of$22,495.00(plus tax) for cabinets and$5,095.00(plus tax) for countertops o Labor to install all cabinets and countertops as specified • Exterior Carpentry o Skylights. This includes • An$1,800.00 allowance for(2)curb-mounted Velux Skylights • Remove and dispose of(2)existing skylights • All carpentry associated with the installation of skylights(ex. Drywall,air sealing,construction and installation of curbs,interior trim,and flashing kits.) o Remove,and dispose of,cedar clapboards up to 18"above roof deck at all roof/siding junctions o Remove,and dispose of,outside corner trim o Install new pre-primed cedar clapboards over new roof membrane—hold approximately 6"above roof o Install new, exterior trim o Remove and re-install storm windows o This contract includes a$150.00 material allowance and 8 man hours for removal/repair of window sills • Subcontractors o Please see the attached document named"Subcontractor Estimate"for each of the subcontractors' respective scopes of work ran; , / "(5) SE,,,,': F ra SCOPE OF WORK August 13,2013 CUSTOMER NAME: Barbara& Matt Pitoniak - ADDRESS: 75 Washington Ave.,Northampton,MA 01060 ESTIMATED START DATE: October,2013 ESTIMATED PROJECT RUN TIME: 6—8 WEEKS TOTAL PROJECT COST: $89,504.69 KITCHEN REMODEL This proposal includes the following: • General administration o Subcontractor procurement and facilitation o Verification of all insurances,licensures.etc. o Building permit application and fees o Standing necessary inspections o Materials ordering and delivery o Site set-up and break-down o Portable Toilet o Certificate of Occupancy • Demolition and Debris Removal o Dust Control o Dumpster o Daily Cleaning o The following items are included: • Existing bi-fold closet area including soffit • (1) Slider door and associated trim • All flooring material (tile and hardwood floors) • All kitchen cabinets and counter tops • All appliances—Remove and dispose of,or relocate for reuse • Miscellaneous Carpentry o All carpentry associated with modifying alcove to accept new kitchen cabinets and countertops. This includes: • All blocking and framing • Drywall and finish • New soffit for upper cabinets o Subflooring • Installation of necessary subflooring material to maintain continuity between two rooms o Miscellaneous blocking,fire blocking,and draft stopping o All miscellaneous carpentry,blocking,nailers,etc. o Washer Dryer Area. This includes: • All framing and drywall • Installation of existing bi-fold doors with new tracks 6d a' • Installation of existing upper cabinet for storage i , f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 1 Congress Street,Suite 100 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): K 13U I LL) ""I2S, //V Address: Si A i e d l�t City/State/Zip: A1C* 1 R m1 f# MA- 010100 Phone#: t/(3.5s(o•s('d Are you an employer? Check the appropriate box: Type of project(required): 1.f I am an employer with 4. ❑I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 7. yg Remodeling 14t"rtA tEt.l. listed on the attached sheet. 2. ❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition ship and have no employees employees and have workers' working for me in any capacity. comp.insurance.$ 9. ❑ Building addition [No workers'comp.insurance 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its officers have exercised their 11.❑ Plumbing repairs or additions 3. ❑ I am a homeownerSeattle8 doing right of exemption per MGL c. 12b(Roof repairs all work myself.[No workers' 152,§1(4),and we have no comp.insurance required.]]' employees.[No workers' 13.❑ Other comp.insurance required.] *My 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.lithe 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 C ompany Name: 7 ra V pe vs s u✓im e Policy#or Self-ins.Lic.#:Z U z g 11 5105 7 S a /- Expiration Date: (o• (1' 26/ Job Site Address:All Locations 75 U Ash in j ur City/State/Zip: vor a vt pr(an M A- Q 1646 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 certify and r the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 8 2 0 - Z 0/ Phone#: 43-08!o- $loco 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#: Z:\Workers Comp Aff-Highlited.doc SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:' Not Applicable ❑ Name of License Holder: SCUT' 1 1" iii a 2— C 5 – 162 4- -7 License Number 61 k 14-4-(-.0 it Sf.1-- A(o a 'ip i MA- 6ID6,0 b• 20 , 2.611-1- Ad ess Ad Date 04-11.1),- ___- 4-/13 .5v0. &oc\ n ture Telephone 9.Reqistered Home Improvement Contractor: Not Applicable ❑ 1C-e- f --€r &, 1d- v', Gil c . (75/6 Company Name Registration Number 51 A- ti-i X ,1f o r-i ko p-f M A- 6/0 Iv d 11 . 29 . Za l5. Address Expiration Date Telephoi LL��l3 b''t dd 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 1083.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to 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 1.52(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 k SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors 0 Accessory Bldg. El Demolition ❑ New Signs ID] Decks [❑ Siding ID] Other[Dj Brief Description of Proposed f' 4.( n yQ 0 d D � re,- re Q P Work: �C.�► -CSI Alteration of existing bedroom Yes 7` 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 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 I, 3w-rt.- k' creel pke,s. 4 IT 6ra /f/t I LI7.t2 , IN 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. SCOTT 1T•-fi Print ame 1.4- 1 $ Z0. 13 Sign.t ire 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 DON'T KNOW © YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW © YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 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 O NO 0 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 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 O NO a IF YES,then a Northampton Storm Water Management Permit from the DPW is required. \J ' ) Department use only J-- - --- 1 , ity of Northampton Status of Permit: uiiding Department Curb Cut/Driveway Permit p$ 2. 0 212 Main Street Sewer/Septic Availability ______\ Room 100 Water/Well Availability of �:voPt�TioN Two Sets of Structural Plans WI.NOR HAMFTON.'hp01060 ••' ampton, MA 01060 p one 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 15 wosh f h J ave. Map Lot Unit f J .-1-- 'nip-him 1Vt i4- 0 10 fo a Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: / / 75 1CtSkl'ng767.v CaV 4Y-f- /5 Name(Print) Current Mailing_AddressY / ��� /3- 5S &— 2l0/l FGAYbxKA /1 Telephone Signature 2.2 Authorized Agent: Weiler 73uildt rr/ • 5/ 4 -jA-E-(eJI °-� IL/omitwip-tr Na e(Pr" t) Current Mailing Address: 4.A/ 4/3-57 '-8tbOti ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 8.9,So 41 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 53'7, 00 5. Fire Protection �� /yam/ 6. Total=(1 +2+3+4+5) S/ 5•01-/• 41 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: � ): — r- P-d 11 Building Commissioner/Inspector of Buildings Date 75 WASHINGTON AVE BP-2014-0209 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 192 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 Pe,„.# BP-2014-0209 Project# JS-2014-000346 Est.Cost: $89504.00 Fee: $537.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 11325.60 Owner: PITONIAK MATTHEW M&BARBARA A Zoning: URB(100)/ Applicant: SCOTT KEITER AT: 75 WASHINGTON AVE Applicant Address: Phone: Insurance: 51A HATFIELD ST (413) 320-9035 WC NORTHAMPTON MAO 1060 ISSUED ON:8/21/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & STRIP & SHINGLE ROOF 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 8/21/2013 0:00:00 $537.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner