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24C-083 (5) 15 MASSASOIT ST BP-2017-1044 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C-083 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2017-1044 Project# JS-2017-001793 Est.Cost: $65000.00 Fee: $422.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq. ft.): 7492.32 Owner: RADKE MARY BETH Zoninu: URB(I00)/ Applicant: KEITER BUILDERS AT: 15 MASSASOIT ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 0 WC FLORENCEMA01062 ISSUED ON:3/24/20.17 0:00:00 TO PERFORM THE FOLLOWING WORK:KITCHEN AND BATHROOM RENOVATION. REMOVE AND REPLACE EXISTING DECK 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 3/24/2017 0:00:00 S422.00 212 Main Street.Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Filet! BP-2017-1044p At3,f'f'ata APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)5864600 Q PROPERTY LOCATION 15 MASSASOIT ST MAP 24C PARCEL 083 001 ZONE URB(IQ,Q,)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONINC FORM FILLED OUT Sfi FeePaidBuilding Permit Filled out Fee Paid TyneofC,n nstruction: KITCHEN AND BATHVATION. REMOVE AND REPLACE EXISTING DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/3Pnt orLicense 102457 fit 3 sets of Pianslans!'PlotfPlan J /E-217eC..724FC<C if. THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INP6RMATION PRESENTED: V Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§, Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: She 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 Demo!' io. relay Signature of I midi g Offici. 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 40k Contact Office of Planning&Development for more information. = Department use only City of Northampton Status of Permit: Building Department Curb CpttDnveway Permit 212 Main Street SeV{artSepbc Availability Room 100 WatertWeU Avaiiatrility ti Northampton, MA 01060 Two Sets of Structural Plans N phone 413-5871240 Fax 413-587-1272 PIotSite Plans Other Specify tV 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 Massasoit StMap Lot Unit lir Zone Overlay District ` l--'-'— Elm St.District as District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Mary Beth Radke IS Massasoit St Name(Print Current Mailing Address: See signed contract Telephone Signature 2 2 Authorized Agent• Keller Builders, Inc 35 Main St Florence, MA lam ringCurrent Mailing Address: a President, KU! 413.5$6-8600 Si/ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COST$ Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 49,000 (a)Building Permit Fee 2. Electrical 6,000 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 7,000 Building Permit Fee 4. Mechanical(HVAC) S. Fire Protection 3'00() 6. Total=(1 +2+3+4+5) Check Number 0.3;37 This Section For Official Use Only Building Permit Number: Date Dated Signature: Building Commissioner/Inspector of Buildings pate Section 4. ZONING Ail Information Must Be Completed.Permit Can Be Denied Due To Incomplete information Existing Proposed Required by Zoning This column m be lilted in by Building Department Lot Size Frontage Setbacks Front Side L: Rt 12 It: Rear Building Height Bldg.Square Footage Open Space Footage `7c Rosi area minus bldg&paved parking) __... #of Parking Spaces Fdt A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ( YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW V YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained a , Date Issued: C. Do any signs existon 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 la NO a 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 V IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all malleable) New House Addition Replacement Windows Alteration(s) Rooting Or Doors Accessory Bldg. Demolition New Signs I I Decks I I Siding( ) Other( Wok: f€�{cR1 R d l�d'� I� tom renovation. Removal and replace existing deck X X Alteration of existing bedroom_Yes No Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sa. If NeW house and or addition to existing housing.complete the following: a. Use of building '.One Family x 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 stones? 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 la•OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i. ...... as Owner of the subject property hereby authorize Keiter Builders, Inc to act on my hnb&u '°matters relative to work authorized by this building permit application. 5 nature of Owner Date 1, Keifer Builders Inc .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 Keiter Name G5-<•..G 02.20.17 President, Keiter Builders. Inc. Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoervlsor: Not Applicable ❑ Name of Lirene Holder Scott Keifer CS-102457 License Number 51 A Hatfield St Northampton, MA 01060 6.20.17 Addrea� Expiration Date ��''y,�''^'�- President.Keifer Builders.Inc 413.586.8600 Signature Telephone 9, Realetered Home Imorovement Contractor Not Applicable ❑ Keiter Builders, Inc 175168 Company Name Registration Number 35 Main Street Florence, MA 01062 4.29.17 Address Expiration Date Telephone 413.586.8600 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 B No ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 Williamsburg, MA City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 15 Massasoit st The debris will be transported by: Keiser Builders, Inc The debris will be received by: Duseau Trucking Building permit number: Name of Permit Applicant Keiter Builders, Inc 02.20.17 President, Keifer Builders, Inc Date Signature of Permit Applicant YTa , The Commonwealth of Massachusetts Department of Industrial Accidents G=;elf= Office ofInvestigations w _.: 1_ - i, _ �.�v 1 Congress Street,Suite 100 e lila; Boston,MA 02114-2017 www.ntass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Keiter Builders, Inc Name (Business/Organization/Individual): _ Address:35 Main Street City/State/Zip:Florence, MA 01062 Phone 4- :413.586.8600 Are you an employer? Check the appropriate box: Type of project (required): I. I am a employer with 18 4. Q I am a general contractor and I 6. ®New construction(full and/or pan-time).` have hired the sub-contractors 2.0 t am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have $. 0 Demolition working for me in any capacity, employees and have workers' 9. ® Building addition [No workers' comp. insurance camp. insurance., required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their - 11.0 Plumbing repairs or additions myself, [No workers' comp. right of exernption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. f No workers i3.0 Other comp. insurance required.] "Any applicant that checks box el must also fill out the section below showing their workers compensation policy information. '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 lox must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees II'thesub-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:Arbella Policy ft or Self--ins. Lic. it:9127440615 Expiration Date:6.11.17 15 Massasoit St Northampton, 0106C .lob Site Address: __. City/State/Zip: Attach a copy of the workers' compensation polity 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 tine 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 DR for insurance coverage verification. I do hereby rtify under the pains and penalties of perjury that the information provided above is true and correct. %a President, Keiter Builders, Inc. 03.16.17 Signature: ... Date: .. Phone 413.586.8600 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense b Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other I Contact Person_. Phone a: / "1 e ACORD CERTIFICATE OF LIABILITY INSURANCE 6n4/ Y6Y1 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: li the certificate holder is on 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 Cynthia Henderson, CISR AME:: N Y Webber & GrinnellMxF .Al. (413)5156-0111 _ tX two.*tall/SU-664Si B North tang Street "AIL AILcdendersan@vebb¢ravd Grinnell.con AFFORDING COVERAGE f NAICF Northampton MA 01060 INSURERA Attalla Protection 141360 INSURED -WSUfl918: _-_ Reiter Builders, Inc. INSURER C: Attn: Scott Reiter INSURER O: 35 Main Street „INSURERS. Florence MA 01062 INSURER F: • COVERAGES CERTIFICATE NUMBER.Master Exp 2017 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 WTH 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. INSR11 0bLFUER POUCY EFF I POLICY EXP - LINnR mi TYPE OF INSURANCE wvo PODGY NUMBER IMMTO/YYYVI IMWOONYYYI R COMMERCIAL GENERAL LIABILITY :EACH CCCUiRENCE S 5,000,000 * ..__. _ F -1 `DAMAGE TO R0gcF0 $ A 1.��4LAIMSMADE I X OCCUR I 'PREMISES fE@gywrren al _100,000 0500064396 6/1/2016 6/1/3019 ! MEO EM ylny tl/PPa $ 5,000 PERSONAL&ADP IN.JuRY 5 1,000,000 SEUL AGGREGATE LIMIT APPLIpp PER'. GENERAL AGGREGATE $ 2,000,000 X POLIO'I .MT .. Lac i PRO 'CTS_COMP,OP AGG 5 ...2,000,000 r OTHER: 5 _ OMOBILE LIABILITY I COMBWED SINGLE LIMIT IE WASP) 1S 1,000,000 ._ i A ANY i i ; BODILYINJURY(Per w ) a ALL OWNED SCHEDULED x aD]oolnaea0] fif Vaol6 1 6/1/]o3Y Boo TY DA(Por ) a . . .autos I mo os 4 x - You+nc.� _ wREO AUTOS � x rAq*omaNEO �SPe. E mu) $ 1 1 I MMiralpaymenit $ 5,000 X IUMBRELLA LIAB OCCUR EACH OCCURRENCE _ 6 5,000 000 A EXCESS LIAO 1IILAIMAMADE' . AGGREGATE 3 5,000,000 DED 'T)RETENTIONS 10,000 4600064399 _ 6/1/2016 l 611/2017 5 IX!WORKERS COMPENSATION PER -OTH- . ANDEMPLOYER6 LIABILITY { STATUTE X 'EH I ROPRETOR/PARTNERIEXPOUT VE Y/N E EACH ACCIDENT 5 1,000,000 OFFFU EXCLUDED? N N/A �I -- AMYandeo(y hiNH) 9127440E15 6/11/2016 6/11/2017 'i EL DISEASE-EA EMPLOYEE$ 1,000000 IOESLR�iPTION OF OPERATIONS bMuv LEL DISEASE POLICY LIMIT $ 1,000,00Q i DESCRIPTION Of OPERATIONS/LOCATIONS/VEHICLES (ACORO 101,AddIlianal Remarks Schedule.may be enevNM If more space Ie required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Far Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C Henderson, CISR/CIN r• I - s1' " o G11988-2014 ACORD CORPORATION. All rights reserved ACORD 25(201401) The ACORD name and logo are registered marks of ACORD INSO/S ever.] T1I.EGRAM SENT OR BY Dn.IVERY. NOT LATER THAN MIDNIGHT OP THE THIRD BUSINESS DAN ECUOW{N{:THE SIGNING OF THIS AGRFFME T Hv sietune this Agreemem. quu acknowledge that you have receis ed a complete and oneinal signed coos of the i r ue Agreement and ataehed Y:xhinrs heat Rudders. Inc. ma} not mart e. ork unu(atter this Aavernem tis ',ern signed DO NOT SIGN7HIS CONTRACT IF THERE ARE ANY BLANK SPACES'. THIS IS a LEC ILLY BANDING AGREEMENT: if-THERE 4RE AN"F' PROVISIONS WHICH YOU DO NOT ANDERSTAND, YOI'SHOULD CONSULT If 1711 AN AT"IUR.AEY BEFORE SIGNING. REITER Bi II HERS, INC. 0%'NEB h. Seatkerctr President 'resident Dt :d Dd.e Daie 6