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32A-143 (17) 40 MAIN ST-EYE PHYSICIANS BP-2018-1279 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:BIOCk:32A- 143 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Catewrv'renovation BUILDING PERMIT Permit BP-2018-1279 Project# JS-2018-002277 Est Cost$105000.0 Fee' $735.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sp.R.): Owner: POIRIER VIRGINIA Zoning,CB Applicant: KEITER BUILDERS AT. 40 MAIN ST- EYE PHYSICIANS ApplicantAddress: Phone: Insurance: 35 MAIN ST (413) 586-8600 () WC FLORENCEMA01062 ISSUED ON.61412018 0.00:00 TO PERFORM THE FOLLOWING WORK LIMITED INTERIOR RENOVATIONS TO EXISTING TENANT SUITE 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 Occuoancv Shmature: FeeTYpe: Date Paid: Amount: Building 6/4/2018 0:00:00 $735.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Vers'ionl 7 Commercial Building Permll Ma I5,2000 Department use only REC6mp n Status of Permit: Building De rtm nt curb Cut/Driveway Permit - MAf 3 �1�@ an tre Sewer/Septic Availability Room 1 0 Water/Well Availability Northam to A 0 060 Two Sets of Structural Plans ghonel t+, qAx 4 3-587-1272 PlotFSite Plans- MP . NORTHATON. A a Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION bP,' S_ /-1 1.1 IT a ass'. This section to be completed by office 40 Main Street, Florence MA Map 3�A Lot /`-f 3 unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) J1fLIla IGL W' POIrIIE�. Current Mailing Address'. r Signature 1 Telephone 413 5 4 (o4dJ- 2.2Authorized Keifer Builders, Inc. 35 Main Street hlorence, MA 01062 Name(Finn Current Mailin Address'. 413-58 -8600 Signature P. Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted hv permit a licant 1. Building a<L/ �j g S (a) Building Permit Fee $0 2. Electrical \9//� 2E / / (b)Estimated Total Cost of t71 b JV b Construction from 6 3. Plumbing id, Lf Building Permit Fee 4. Mechanical(HVAC) $0 5. Fire Protection 6. Total=(1 + 2+ 3+4+5) IOS 0" 1 Check Number This Section For Official Use Only Building Permit Number Date Issued Signature'. Building Commissionerlinspector of Buildings Date Version].7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ✓❑ Existing Wall Signs ❑ Demolition E] Repair❑ Additions Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs g❑❑ RoofinChange of Use❑ Other ❑ Brief Description Limited interior renovations to existing tenant suite. See plans attached. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly O A-1 13 A-2 © A-3 a 1A A-4 C1 A-5 0 IB �] B Business 0 2A E Educational Ell] 2B F Factory 0 F-1 0 F-2 2C H High Hazard 0 3A Institutional 0 1-1 1-2 0 1-3 36 M Mercantile 4 (� R Residential 0 R-1 0 R-2 R-3 0 5A S Storage ® S-1 S-2 5B U Utility 0 Specify: M Mixed Use Specify: S Special Use La Specify. COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(si) 1 1:i 2 e 2" 3 3,a ra 4" 4m Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) Total Height it 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ® Private n Zone Outside Flood Zone E] Municipal M On site disposal system❑ Vcrsionl 7 Commercial building Permit May 1i,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning "Ibis column m be fillet in by Building Dcpnnmeni Lot size Fronlallc Setbacks Pr nt Side 1: R:_ U R: Rear Building Fright bldg.Square Footage k Open Space Footago We (La arca minus bldg&pa,,d parking) N A Parkin, Spaces fill: (r(,Iumc&lucanwn) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 O , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version)7 Commercial Building Permit Ma) 15.2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable 0 Name(Registrant) Registration Number Address wA� (f•--� Expiration Dale Signature V__ Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Keifer Builders, Inc Not Applicable T] Company Name. Scott Keifer Responsible In Charge of Construction 35 Main St. I-lorence, MAO 1062 A ess 413-586-8600Pres Jen Kn Signature Telephone Vcrsionl 7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Re aired Yes © No Q SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize r--'= r V QVxJCAS , to on my behalf, in all matters relative to work authorized by this building permit application. /1 - )1) h,o � 30 tuts sigratuqof Owner Date Keiter Builders, Inc 1. , 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 Print r#e 4.24.18 Sign ore of OwnerlAgent Data SECTION 12-CONSTRUCTION SERVICES 10.1 1,censed Construction Supervisor: Not Applicable ❑ Scott Keiter CS-102457 Name of License Holder'. License Number 51 A Hatfield Street 6/20/18 Atlggqrrrgggss Expiration Date ',� 413-586-8600 nature TeIaphorre SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(e)) 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 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: 40 Main Street,Florence MA The debris will be transported by: Keiter Builders, Inc. The debris will be received by: valley Recycling Building permit number: Name of Permit Applicant Keiter Builder Inc 528_18 President, H131 Date Signature of Permit Applicant �V ...� .............*..mow.., � ....,,,,....,.... .,..., Department of IndustrialAccidents Ogee of Investigations I 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 Keiter Builders, Inc. Name (Business/Organization/Individual): Address: 35 Main Street City/State/Zip: Florence, MA 01062 Phone #:413-586-8600 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 am a employer with 20 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ® New construction 2.® 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. ® Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.® 1 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.] ` c. 152, §1(4).and we have no employees. [No workers' [3.0 Other comp. insurance required.] *Any applicant that checks box NI must also Fill out the section helow showing thcinvorkers courpsns'ation policy information. t Homeowners who submit thisaffidavit indicating they are doing all work and then him outside contractors must submit a new a nidavit indicating such. Convectors that check this M,z must attached m additional sheet showing the name orthe sub-contractors and state whether or nouhose entities have employees Itthehave employees,they must provide their workers comp.policy number. d nm an employer tient is prrwiding workers'compensation insurance for my employees. Below is are policy and job site information. AIM MUTUAL Insurance Company Name: Policy # or Self-ins. Lia W MZ80080071392017A#: Expiration Date:6/l/18 40 Main Street Florence, MA Job Site Address City/State/Zip: _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tine 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. d do herehy rtify under the pains and penalties of perjury that the information provided above is true and correct. SienalUre' X� President 5.28.18 FBI - Date' Phone#: 413586-8600 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �® CERTIFICATE OF LIABILITY INSURANCE °6/29/22017 ' 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(les) must be endorsed. 11 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 —. AX Webber L Grinnell FH(Ati.anEn): (613)586-0111 lNN_(au) 86-0afil 8 North Hing Street AMAILSS;chenderson@webberandgrinnell.com —. _. - _— __IN_SURER(5)AFFORDING COVERAGE RAIDY Northampton Np 01060 INSURER ASelective _ ,.192.5.9 INSURED 1SB URERBA.I.M. Mutual Hester Builders, Inc. INSURER C'. Attn: Scott Reiter INSURERS: 35 Main Street INSURER E'. Florence ME 01062 INSURER R COVERAGES CERTIFICATE NUMBERJMaster Erp 2018 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 NOTWITHSTANOING 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. 1DDL SUBP PoLICY EFF PLICY ESP O INSP T rypE OF INSURANCE F ICV R YY LIMITS X COMMERCIAL GENERAL UMBILIT' EAL H OCCURRENCE_ S 1,000,000 D A E TO RENTED r A CLNMSMPDE X OCCUR , PRE.ISES(GS eFVme_�) S _ 100,000 I 52265561 6/]/201] 6/1/2018 RED F P(My one pmwnl s 51000 _ PERSONAL 6 MV INJURY $ 1,000,000 GEN i AGGREGATE LIMIT APPLIES PER _ GENERAL AGGREGATE $ 2,000,000 X POLICY PRO GO�J LpC ' PRODUCTS COM%ORAGO S 2,°00_r 000 OTHER S AUTOMOBILE LIABILITY 2MBI reorNEOI SINGLE L IMIT $ 1,000,000 A ANY MITO BODILY INJURY(Per pen'On) $ -. AIL OWNED - I SCHEDULED awtlen0I s 6/t/30l'I 6/]/2018 BODILY INJURY IP AUTOS x) NON OARED A910521] � PROPERTY DAMAGE X NRLCAUTOS Xa ,-TOS (P,—ienU Mereol a ems E 5,000 X UMBRELLA LIAR I OCCUR RICH OCCURRENCE is _ 5,000,000 A ENCE55"A. LLNMSM.E AGGREGATE �_ FEES X RETENTION 10.000 52265567 6/1/2017 1 6/1/2018 5 IWORNER$COMPENSATV. X SEATVTEI '4 ERH AND EMPLOYERSLIABILRV – -- ANY PROPRIETOR""TNER/EXECUTVE Y/�I N/A EL EACII ACCIDENT s 1,000,000 OFFICERIMFMOER EXCLUDEDI L . B ISIINS. In NN) iM 980080071392017A 6/11/2017 6/Il/2015 FL OISEASC FA EMp LOVEE S 1,000,000 Hy s RIPTIOountler EL DISFASE POLICY LIMIT s 1000000 °ESCeseer) OF OPtRATIONS pelOw SCRIP,mNOFa'E "0R5/LOCATIONS/VEHICLES(AC°RD101."diflOnYRw *,$ hulamaybeWucMdilmWeWcewreulteI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE AL' C Henderson, CISR/CIN ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014A1) The ACORD name and logo are registered marks of ACORD INSAG,F vmenn Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the ninth edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Renovations for Eye Physicans of Northampton,Suite 104 Date:05/24/2018 Property Address: 40 Main Street,Florence, MA 01062 Project: Check (x) one or both as applicable: New construction X Existing Construction Project description: Limited interior renovations to existing tenant suite I Richard E. Katsanos MA Registration Number: AR8355 Expiration date: 08/31/2018 , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': X Architectural Structural X Mechanical Fire Protection X Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, Ishall submit held/progress reports (see item 3.) together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a 'Final Construction Control Document'. Enter in the space to the right a "wet" or Richard E. Digitally signed by Richard E Katsanos IKT electronic signature and seal: Date:2018.05.2413:43:40 pF�N' Katsanos -0400' WqO P,�yallos Phone number:413585-1512 Email: Richard.Katsanos@HAlArchitecture.com Building Official Use Only y ,� m s =Bm1dmg0ffi,We: Permit No.: Date: LbM1l1 Note 1. lndicale with an'x'project design plans,compulations and specifications ital you prepared of chosen,provide a description Version 01 01 2018