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31A-064 (5)
1 PARADISE RD-KING&SCALES BP-2021-1301 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31A-064 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2021-1301 Project# JS-2021-002148 Est.Cost:$150000.00 Fee: $1050.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 13198.68 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(100)/URC(100)/ Applicant: KEITER BUILDERS AT: 1 PARADISE RD - KING & SCALES Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON:5/11/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:PAINTING AND REPAIRS 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. V • • Certificate of Occupancy Signatu i,a• X� I 1 FeeTvpe: Date Paid: Amount: Building 5/11/2021 0:00:00 $1050.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner i MAY - 7 2021 N.,tWSr�CT(QNS fla enweatth of Massachusetts Office of Public Safety and Inspections / Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling rr� ('This Section For Official Use Only) Buildhig Permit NumberVr'-.1/—1 W Date Applied: _ Building Official: SECTION 1:LOCATION 1radise Road - King a Scales . . No.and Street City/To�^ Q� Zip Code Name of Building(if applicable) Assessors Map* Block H and/or Lot t! SECTION 2 PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply the two rows below PP Y in Existing Building❑ Repair tX Alteration ❑ Addition❑ Demolition 0 (Please fill out and submit Appendix 2) Change of Use O Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: ai..t rig.an "miscellaneous wexterior repairs SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s):_ SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)lc Area Per Floor(sq.IL) NA Total Area(sq.It)and Total Height(ft.) NA SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5© B: Business ❑ E: Educational 0 F: Factory F-1 0 F2 0 1 H: High Hazard H-1 0 H-2 0 1-1-3 0 H-4© H-5 0 I: Institutional I-I 0 1.2❑ 1-3© I-4❑ M: Mercantile© R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) LAD IBO LIAR 13B0 HIA © MBf3 IV VA13 VBO SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public CA Check if outside Flood Zone® Indicate municipal m A trench will not be Licensed Disposal Site X1 Private 0 or indentify Zone: __ or on site system 0 required In or trench or specify: ,w� permit is enclosed❑ USA Waste Railroad right-of-way: Hazards to Air Navigation: jv1A Historic Commission Review Prom* Not Applicable CI Is Structure within airport approach area? is their review completed? or Consent to Build enclosed❑ Yes 0 or No LI Yes❑ No EX SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: _Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner /! ' i,e.t ter` )'U .tt2'+ `S ' ,E cord/, 7! /. , OA7 J` " '4 ./lar.P /42, ?' 4017 r?y CS ,? Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ev )4 "Lir 3 y3.60,1- - - i /'6-cvi ef/Nt7 ve,/ Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: elan- - ,177 Name Street Address City/Town State Zip to apply far and act on the property owner's behalf,in all matters relative to work authorized by this building pit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here Otherwise ovide co •on control f see section 107 in the code es 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) • Laura Fitch 413.549 5799 ifitch@facdarchitects.com ; 8835 Name(Registrant) Telephone No. e-mail address Registration Number Amherst,MA Architectural 8/21 Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor Keiter Corporation Company Name Scott Keiter CS-102457 Name of Person Responsible for Construction License No, and Type if Applicable 35 Main Street Florence,MA 01062 Street Address City/Town State Zip 4 t�586 8800 _Ai-a.m.9035 skeiter@keiterbulklers.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WO ME ENSATl N INSURANCE AFFIDAVIT G.L.c.152. 25C 6) A Workers'Compensation Insurance Affidavit iroLn the MA Department of industrial Accidents 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. Is a signed.Affidavit submitted with this pplication? Yes XI No Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE I Estimated Costs:(Labor I Item and Materials) Total Construction Cost(from Item 6)=$ 1,050 I.Building S 150,000 Building Permit Fee=Total Construction Cost x 150(insert here 2 Electrical $ appropriate municipal factor)= 3.Plumbing S, 4.Mechanical (HVAC) S Note:Minimum fee=S (contact „••'cipaIity,)-� 5.Mechanical (Other) $ Enclose check payable to L 16 6.Total Cost $ 150,000 (contact municipality)and write check numb•,01 � Mill SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Please print and sign name Title Telephone No. Date Street Address City/Town State Zip Email Address c q Municipal Inspector to fill out this section upon application approval: Ins :VP! • ' 1 Name a 6.0 m11240 The City of Northampton • Building Department 212 Main Street rtp,u+0,�~ Northampton,Massachusetts 01060 Phone(413) 587-1240 Fax(413) 587-1272 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVAT ION PROTECTS) In accordance with the provisions of MGL c40, s54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111,s150A. The debris will be disposed of in: Valley Recycling Location of Facility Easthampton St Northampton,MA The debris will be transported by: USA Waste Name of Hauler USA Waste Signature of Applicant © Date: 5/4/21 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 rm Boston,MA 02114-2017 t+nvw ntass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibh Name(Business/Organization/Individual): Kaiter Corporation Address:35 Main St City/State/Zip: Florence.MA 01062 Phone#: 413-586-8600 Are you no employer?Check the appropriate hoer Type of project(required): l.®I am a employer with 35 employees(full and/or part-time)." 7. ©New construction 2.01 are a sole proprietor or partnership and have no employees working far me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.) 3.O 1 tun a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct di work on ray property, I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.DPlumbing repairs or additions 5.©i am a general contractor and I have hired the subeonenrou)rs listed on the attached sheet. 13.�Roof repairs These subcontractors have employees and have workers'cramp,insurance, 6.0 We ore a corporation and its officers have exercised their right of exemption per h 0L c. 14•[]Oilier 152,11(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box gl muss also till out the section belay,'showing their workers'compensation policy information. t Homeowners who subrnit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating Such. 1Cootramars that check this box must ranched an additional sheet showing the name of the sub-contraaors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lie.#:MCC20020005382020 Expiration Date: 6/11/21 lob Site Address: 1 'orddi$e Road _ City/State/Zip; Northampton, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under e ins and penalties of perjury that the information provided above is true and correct, i ature: Z Date: 5/4/21 Phone#: 413.586-8600 Official use only. Do not write in this area,to be completed by city or town official City or Town: Pertait/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#: R©�A CERTIFICATE OF LIABILITY INSURANCE VA 05/29/2020 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 have ADDITIONAL INSURED provisions or be endorsed. H SUBROGATION IS WAIVED,subject to the terms end 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(*). PROOUCER CONTACT Cyndle Henderson CISR,CPIA NAME Webber 6 Grinnell rMONE (413)586-0111 8 North KingStreet °•axe; ! No (413)355-fi481 ADD ss: chendersontlwebbenndprtnnell.com INeIIRERI51 AFFORDING COVSRAOE NAIC s Northampton MA 01060 IMSum*A: Selective Ins Co of S Caroline 19259 INSURED INeURdt b: A.I.M.MuIuaYA.LM. Falter Corporation ImUttER C Attn:Scott Kellar INSURER 0 35 Mein Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2021 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 POLICES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRER ADDL' POLICY ►O TYPE OF INSURANCE DiryyQ POLICY NUMBER trwoom'rPYt ILaMrpoRRIVrvvrTT LIMITS . x COMMERCIAL GENERAL LIAe1LfTY EACH OCCURRENCE i 1,000.000 ® DAMAGE 1 O RL:NTEO 500 D00 CL.AbtsNADE OCCUR PREMISES(EE ocos,.l l , — MED EXP iAn wean a» can S 15,000 A — S2265567 06/01/2020 06/01/2021 PSRsoNALa ovsluny t 1,000,000 OEM.SOOREQATE LIMIT APPLiES PER GENERAL AGGREGATE t 2,000,000 _ PotJLY a RPRA, LOc PRODUCTS-COMP/OPAOC s 2.000,000 OTHER AUTOMOBILE LMBI.m r�TINED SINGLE UNIT s 1,000,000 j<ANY ALITO BODILY INJURY(Per person) $ A —OwNED .._._SCHEDULED A9105217 06/01/2020 06/01/2021 So0ILY slum mot a idem) S AUTOS ONLY AUTOS HIRED HON.OWNED PROPERTY DAAMOE $ AUTOS ONLY AUTOS ONLY IPIr raldIMI Medical payments $ 5,000 X uraRELULL1Aa XOCGUR EACH OCCURRENCE f 5,000,000 A Baas*We CWMS.MADE S2265567 06/01/2020 06/01/2021 AGGREGATE >; 5,000,000 OED >4 RETENTION$ 0 $ WORICERRJ COMPENSATION SPUTUM TT+ AND EMPLOYERS'LIABILITY STATUTE PR ANY PROPRIEIORIPARTNERSRECUTTVE Y1 N EL EACHACCIDENT f 1,�,000 B oFFICERrMEM1NER EXCLUDED? n w,A MCC20020005382020 06/11/2020 06/11/2021 1,00 • 0.000 (Mandatory In NH) EL DISEASE.EA EMPLOYEE S N Yp,wwAe ender 1,000 000 DESCRIPTION OF OPERATIONS below EL DISPASP-POLICY UMR e DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEFSCLes(Aeon 1e1.AdIYbnu Reworks Sct»dul.,mry a INRIGH d N wwi.fpr•r rpulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POtICEES BE CANC FI I fD BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "'Evidence of Insurance•"' ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE � - rsi„ fA 1688.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and Ingo are reglstersd marks of ACORD