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31A-068 (4) 196ELM ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1939 Map:Block:Lot:31 A-068- 001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-1939 PERMISSION IS HEREBY GRANTED TO: Project# FOUNDATION REPAIRS Contractor: License: Est. Cost: 10000 KEITER CORPORATION 102457 Const.Class: Exp.Date:06/20/2022 Use Group: Owner: SMITH COLLEGE Lot Size (sq.ft.) Zoning: EU/URC Applicant: KEITER CORPORATION Applicant Address Phone: Insurance: 35 Main St. (413)586-8600 0 MCC200200053820121A FLORENCE, MA 01062 ISSUED ON:09/27/2021 TO PERFORM THE FOLLOWING WORK: FOUNDATION 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. Signature: Tit • I II Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 • Office of the Building Commissioner Th Commonwealth of Massachusetts SEp 2 3 Office of Public Safety and Inspections 2�21 Massachusetts State Building Code(780 CMR) Buoilding Per�FCCT orvis App 'cation for any Building other than a One-or Two-Family Dwelling �� rnr n�Nr OF (This Section For Official Use Only) lCTuatb ,rn� Building Permit ,_ Mq o i oso Da e Applied: Building Official: 3 O _ 21. 14M SECTION 1:LOCATION 196 Elm Street No.and Street City/Town D G� Zip Code Name of Building(if applicable) Assessors Map# Block T#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair Jg/ Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ® No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No El Brief Description of Proposed Work: Foundation 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) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) NA Total Area(sq.ft.)and Total Height(ft.) NA SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub ❑ A-3 0 A-4 0 A-5 0 B: Business Cl E: Educational ❑ F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑ S: Storage S-1❑ 5-2 0 U: Utility 0 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ MB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis osa]Site ] Public G Check if outside Flood Zone El Indicate municipal ❑ A trench will not be p required in or trench or specify: Private 0 or indentify Zone: or on site system❑ permit is enclosed 0 USA Waste Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable® Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No iJ Yes❑ No RI 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 Trustees of Smith College C/O Karl Kowitz 126 West Street Northampton, MA 01060 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Project Manager 413.585 2404 kkowitz@smith.edu Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Keiter Corporation 35 Main Street Florence, MA 01062 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit 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 g. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) • NA-See control waiver Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 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 _4i 1.5$6 8600 41-3 320. 9035 skeiter@keiterbuilders.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes El No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 10,000 Building Permit Fee=Total Constructio ost x (Insert here 2.Electrical $ appropriate municipal facto =$ a i . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 10,000 (contact municipality)and write check number here jL f 16 V 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 applicatio,,*�. e arid accurate to the best of my knowledge and understanding. �- Scott Keiter, President 41 3-586 8600 Please p4 t and sign name Title Telephone No. Date 35 Main Street. Forence, MA. 01062 skeiter@keiterbuilders.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: 04434., 1' T� -12yol_ Name 'U Date rat4,. The City of Northampton `�"[[[��" Building Department ' �_,.. i Main212 Street y� °R"rf0S91E111� Northampton, Massachusetts 01060 Phone (413) 587-1240 Fax (413) 587-1272 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVAT ION PROJECTS) 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 . 1 Signature of Applicant: \ Date: 9/21/21 ° N_ The Commonwealth of Massachusetts f� Department of Industrial Accidents !� = 1_ 1 Congress Street, Suite 100 Boston, MA 02114-2017 `� www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Keiter Corporation Address: 35 Main St City/State/Zip: Florence, MA 01062 Phone#: 413-586-8600 Are you an employer?Check the appropriate box: Type of project(required): L®I am a employer with 45 employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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. 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 Company Name: AIM Mutual Policy#or Self-ins.Lic.#:MCC20020005382021A Expiration Date: 6/11/22 Job Site Address: 196 Elm Steet 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$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.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. Signature: ,� i'v Ti••s.4_4 e82---- Date: 9/21/21 i Phone#: 413-586-8600 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC�® DATE(MM/DD/YYYY) �,. CERTIFICATE OF LIABILITY INSURANCE 06/16/2021 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 have ADDITIONAL INSURED provisions or 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 Cyndie Henderson CISR,CPIA NAME: Webber&Grinnell PHONo,Ext): A (413)586-0111 FAX No): (413)586-6481 (A/8 North King Street E-MAIL chenderson@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: Selective Ins Co of S Carolina 19259 INSURED INSURER B: MA Employers/A.I.M. 12886 Keiter Corporation INSURER C: Attn:Scott Keiter INSURER D: 35 Main Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2022 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2021 06/01/2022 PERSONAL&ADV INJURY $ 1'000,000 GENIIAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105217 06/01/2021 06/01/2022 BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5'000'000 A EXCESS LIAB CLAIMS-MADE S2265567 06/01/2021 06/01/2022 AGGREGATE $ 5,000,000 DED X RETENTION $ 0 $ WORKERS COMPENSATION X STATUTE X ERR- AND EMPLOYERS'LIABILITY Y/N 1 B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A MCC20020005382021A 06/11/2021 06/11/2022 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 ""Evidence of Insurance"" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I l-•1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD KEITER 35 Main Street.Florence•MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilders.com Commissioner Flagg 9/21/21 Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the 196 Elm Street Foundation Repair Project at 196 Elm Street in Northampton because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Ma Respectfully, I'� . 4 i Scott Keiter Keiter Corporation 35 Main St Florence, MA 01062