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24C-144 ACORL , CERTIFICATE OF LIABILITY INSURANCE 06/06 /22011 011 06/06 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 pobcy(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 NAME: Webber & Grinnell Ins. Agency, Inc. P HONE Exq: 413. 586 c , N o ) : 413.586.6481 8 North King Street E-MAIL Northampton, MA 01060 PRODUCER 00021099 CUSTOMER ID f: INSURER(S) AFFORDING COVERAGE NAIC f INSURED INSURER A: Travelers Casualty of America Keiter Builders, Inc. INSURER B: Travelers Companies, Inc. 51A Hatfield Street INSURER C: Northampton, MA 01060 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: Master Exp 06/12 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 ASR S y yV PO LICY NUMBER POLICY EFF POLICY EXP LIMITS {MMIDDIWYI) iMMIDDM'YY) GENERAL LIABILITY I6806319N661ACJ11 0610112011 0610112012 EACH OCCURRENCE $ 1, 000, 000 X COMMERCIAL GENERAL LIABILITY PREMISES ( a o $ 300,000 PREMISES (Ea occurrence) CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY '-- PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS C O M PENSATI O N UB2A56578 06/11/2011 06/11/2012 X T LIMITS S ER AND EMPLOYERS' LIABILITY Y IN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N J NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 Ir yes, describe under DESC OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 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. AUTHORIZED REPRESENTATIVE " F or Information Onl ( Y �" � Cynthia Henderson, CISR /CINDY O 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD CONTRACTOR'S LIMITED WARRANTY KEITER BUILDERS, INC. 51A Hatfield St. Northampton, MA 01060 Phone: 413 - 320 -9035 Fax: 413 - 280 -0124 The contractor signatory below Keiter Builders, Inc. ( "Contractor ") hereby guarantees David & Clare Perry ( "Owner ") that the construction performed on that certain structure located at 13 Arlington Street, Northampton, MA to be free from defects due to workmanship for a period of one (5) years from the date of commencement of use, substantial completion or date of notice of completion, whichever is the first to occur: This Standard Limited Warranty applies and is limited as follows: 1. To the property only as long as it remains in the possession of the original owner named above. 2. To the construction work that has not been subject to accident, misuse or abuse. 3. To the construction work that has not been modified, altered, defaced, or had repairs made or attempted by others. 4. That Contractor be immediately notified in writing within ten (10) days of first knowledge of defect by owner or his agent. 5. That Contractor shall be given first opportunity to make any repairs, replacements or corrections to the defective construction at no cost to owner within a reasonable period of time. 6. Under no circumstances shall Contractor be liable by virtue of this warranty or otherwise for damage to any person or property whatsoever for any special, indirect, secondary or consequential damages of any nature however arising out of the use or inability to use because of the construction defect. // , test - / 7 -// gnature Date r r ::h . _BUILDERS SCOPE OF WORK October 17, 2011 PROJECT: NEW ROOF (Back Roof Area) — Approximately 6 Square CUSTOMER NAME: David & Clare Perry ADDRESS: 13 Arlington Street Northampton, MA 01060 ADMINISTRATION Keiter Builders will manage all aspects of this project, including the following: o Applying for building permit o Standing all necessary inspections o Materials ordering and delivery o Waste Removal and Site Clean-up ROOF o Remove and dispose of approximately 600 square feet of shingles and small section of rolled roofing o Install Ice and Water along eaves and valleys o Install 30 lb felt paper or equivalent o Install 8" white drip edge along perimeter of roof o Install (3) new vents and (1) vent boot o Install 30 year architectural shingles (color to be chosen by customer) o Install new granulated, rolled roofing (approximately 50 square feet) TOTAL PRICE INCLUDING ALL MATERIALS AND LABOR: $2,400.00 KEITER BUILDERS, INC. HOMEOWNER +° r � by, J Cott Keiter, its president Date Date _ e 10- y -( Date 6 REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A. KEITER BUILDERS, INC. HOMEOWNER t /0 —/-7-1/ I ll b 0 By cott Keiter, its president Date Date �.r... AA d. w) I Date NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIA'I'ED 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. 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. 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. 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. 5 the limit of coverage, if necessary, to reflect the estimated replacement cost. You will be responsible for any co- insurance penalties or deductibles. If the work covers an addition to or is adjacent to an existing building, You and Keiter Builders, Inc. agree to waive all rights against each other for damages caused by fire or other perils to the extent covered by insurance. RIGHT TO TERMINATE CONTRACT: If the work is stopped or delayed, either in whole or substantial part, for a period of thirty (30) days under an order of any court or other public authority having jurisdiction, or as a result of an act of government and due to your fault or negligence, or as a result of an act within your control; or if the work shall be stopped or delayed either in whole or substantial part, for a period of theirty (30) days due to your failure to make a payment on time, or make Keiter Builders, Inc. feel insecure, or if you should commit a material breach of any of your responsibilities or obligations under this Agreement, then Keiter Builders, Inc. may, upon giving you seven (7) days written notice, terminate this Agreement and recover from you payment for all work performed; for any unpaid costs of and fees for the work; for any liability, obligations, damages, commitments, and/or claims that Keiter Builders, Inc. may. have incurred or might incur in good faith in connections with this Agreement, as well as receiving payment for Keiter Builders, Inc. attorney's and legal fees and all lost anticipated gross profits on the work not performed as of the date of the termination. NOTICE: Notice will be deemed if delivered in hand or if sent by certified mail, return receipt requested, to the address listed on the front page of this Agreement. WARRANTIES: Keiter Builders, Inc. will grant you, as part of the Total Price, a Limited Warranty, a copy of which is attached to this Agreement. Keiter Builders, Inc. will use materials that are currently acceptable for their intended use in performing work. You should be aware that it may be determined that some of these materials may cause health problems. If there are any materials that you do not want used in the work, list them on the attached Scope of Work form. EXHIBITS: The following Exhibits have been attached to this Agreement: Scope of Work Limited Warranty ARBITRATION: THE CONTRACTOR AND THE HOMEOWNER 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 4 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. ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED THE 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. SUBCONTRACTORS: Keiter Builders, Inc. intends to hire the following subcontractors to assist in the work: Name N/A 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. INSURANCE: Keiter Builders, Inc. shall purchase and maintain liability insurance for protection of all claims under workman compensation acts and other employee benefit acts, claims for damages because of bodily injury, including death, and from claims for damages, other than to the work itself, to the property which may arise out of or result from my operations under this Agreement. You shall purchase and maintain property insurance in a form acceptable to Keiter Builders, Inc. upon the entire work and materials for the full cost of replacement as of the time of loss. The insurance shall insure against the loss from perils of fire, extended coverage and shall include "all risk" insurance for physical loss of damage, including without duplication of coverage, at least theft, vandalism, malicious mischief, transit, collapse, flood, earthquake, testing and damage resulting from defective design, workmanship or material. You will increase 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 30 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 Two Thousand, 'four Hundred ($2,400.00) DOLLARS. Payments against work completed and materials delivered will bel 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. 3% of Total Price. (Non - Refundable Deposit) ($72.00) 33% of Total Price due prior to initiating work. ($792.00) 64% of Total Price due at Substantial Completion. ($1,536.00) All sums not palid 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. fells secure in obtaining the remaining payments. If there is any stoppage in work due to your 2 CONSTRUCTION AGREEMENT Keiter Builders, Inc., of Northampton, MA whose Federal Tax Identification Number is 27- 2518846, Contractor's Registration Number 163295 (Exp. 06 -01- 2013), and License #102457 (Exp. 06- 20- 2012), is entering into this Agreement with you David & Clare Perry of 13 Arlington Street, 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 13 Arlington Street, 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 Electrical Permit Smoke Certificate 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 ACORP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYY`n 06/06/2011 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 certficate holder is an 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 NAME: Webber & Grinnell Ins. Agency, Inc. t N E,rq: 413.586 ( F AI x No): 413. 586.6481 8 North King Street E-MAIL ADDRESS: Northampton, MA 01060 PRODUCER 00021099 CUSTOMER ID /: INSURER(S) AFFORDING COVERAGE NAIC as INSURED INSURER A: Travelers Casualty of America Keiter Builders, Inc. INSURERB: Travelers Companies, Inc. 51A Hat Street INSURER C : Northampton, MA 01060 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: Master Exp 06/12 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 INSR S WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDD/YYYY) (MM/DDl1'YYY) GENERAL LIABILITY I 6806319N661ACJ11 06101/2011 06/01/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE REMI E TO ( RENTED $ 300,000 PREMISES (Ea occurrence) CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5, 000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS _ PROPERTY DAMAGE HIRED AUTOS (Per accident) NON -OWNED AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION UB2A565782 06/11/2011 06/11/2012 X TORY LIM TS W- AND EMPLOYERS' LIABILITY Y I N - B OFFICER/MEMBER Y PRIETO EXCLUDEDR /EXECUTIVE I N N E L. EACH ACCIDENT $ 100, 000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100, 000 D yes, descrie under DESCRIPTIO OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I 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. AUTHORIZED REPRESENTATIVE =?=' For Information Only » - - ° - Cynthia Henderson, CISR /CINDY www✓ ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ _ 600 Washington Street 1` °" Boston, MA 02111 i www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information II // Please Print Legibly Name ( Business /Organization/Individual): KEt TCfl & I L-b it S 2Nc Address: S 1 ik 1Etrl, ST. City /State /Zip: Wort, 0A , DI Dbp Phone #: 4 ,13 - 3 ZO -903S Are you an employer? Check the appropriate box: Type of project (required): 1. [ I am a employer with 3 4. [] 1 am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. E] New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub - contractors have 8. [] Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.t required.] 5. LI We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.111 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.tg Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 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 box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the 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: 1 'J E L&t, S Policy # or Self -ins. Lic. #: U 2 2 A 5 t S` 7'l.? Z Expiration Date: ( - 1 t - 1 2 Job Site Address: ) 3 A' 6 Tb N ST. City /State /Zip: Pon ltki4 D I o to o 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 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 D1A for insurance coverage verification. I do hereby certify u er the 1-e/h-- pains t ai ins andppenalties of that the information provided above is true and correct. Signature: ) likes Date: 1 Z -,- I I Phone #: i ll3 - 3Lo - 9 0 35 - 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 #:_ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1,_ Not Applicable ❑ Name of License Holder : Sc lE 1T _ I 0,1 Lf S 7 t r n License Number A S A PrfiEa Si' hoetri -r,4 P97 DMA °lobo o49 - . Z o — .2o► Addles Y Expiration Date _...../._ 9/3 - 3 Zo — 90 '3 S r-- S ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ /e /r&. guic , Sv c, 1 to 3 2 9 S Company Name Registration Number SIA 144- per -bsr. 0G--01-. o\ Address Expiration Date /Aiv,L 4, T1W, AA 0!0b0 Telephone y/3 320 - 9o 3 — 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 108.3.5.1. 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 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing 1:'I Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other [0] Brief Description of Proposed Work: rap c_Ac E a pp ¢.OK i'vtA AT 1f (o 57vivit e oc eo s-C ' gAC k o f t�pM� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 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 �� EXkS r Z "J6 b. Number of rooms in each family unit: Number of Bathrooms i2 ec)(A GE 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. Asq_ SEE iTr".Actt€r CONTRACT Signature of Owner Date I, , as Owner /Authorized Agent reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and ef. Signed under the pains and penalties of perjury. Print Name � Q f . ./ T /���^ -�,� l Z. — i — I [ Signat ,a` of Owner /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 DONT KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (3 DON'T KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES (3 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 l NO 0 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 0 NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. p REC VE D Department use only ity )f Northampton Status of Permit: DEC 6 2011 uilcing Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability °F rt hampton, MA 01060 Two Sets of Structural Plans tw►m pone 41.E -5isr -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 13 A+2 LI nss ro. ■s ST • Map Lot Unit Np, -raN s I &A A 0 CO 6° Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: n y 1OAV 17 ji Cx..k s Q P�Q2 i 13 {��1..-Irva:76N S Name (Print) Current Mailing Address: C SS- SEE ATTPGt1Eb COADVA Cr Telephone Signature 2.2 Authorized Agent: kE-r rt Q u r- >E 2 S i s✓v C. c l A (-1,9-170 I e ST. N A1.{fripnr J' ag1A— Name (Print) Current Mailing Address: " -- ) P 4`1 3 - 310 - `jom Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 5 .2 r x o0 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) $ , 40 0 .00 Check Number 0 2 f , i ----- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 13 ARLINGTON ST BP- 2012 -0542 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 144 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2012 -0542 Project # JS- 2012 - 000909 Est. Cost: $2400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 13155.12 Owner: MOORE GLENN E & LUCIE ANN CIO DAVID B PERRY Zoning: URB(100)/ Applicant: SCOTT KEITER AT: 13 ARLINGTON ST Applicant Address: Phone: Insurance: 51B HATFIELD ST (413) 320 -9035 WC NORTHAMPTONMA01060 ISSUED ON:12/6/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 6 SQ 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 12/6/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner