25A-095 CONTRACTOR'S LIMITED WARRANTY
KEITER BUILDERS, INC.
51A Hatfield St.
Northampton, MA 01060
Phone: 413 - 320 -9035
Fax: 413 - 586 -1890
The contractor signatory below Keiter Builders, Inc. ("Contractor ") hereby guarantees Dan and
Carolyn Kibe ( "Owner ") that the construction performed on that certain structure located at 354
Bridgge Street, Northampton, MA to be free from defects due to workmanship for a period of
one (1) year 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.
Signature Date
PAINT
o Prime and paint all walls / ceiling in bathroom, utility area, and bedroom closet area
o Prime and paint all interior trim in bathroom, utility area, and bedroom closet area
o Prime and paint all new shelving in bedroom closet and utility room
o Prime and paint wainscoting and chair rail in bathroom
o Sand / prep, prime and paint window sash units in bathroom
o All caulking
PLUMBING
o Plumbing permit and inspections
o Make all plumbing connections to new toilet and shower
o Install all plumbing fixtures
o Re- connect sink and radiator
o Plumbing fixtures to be provided by customer
o Please note that proposal assumes that existing chase can be used
ELECTRICAL
o Electrical permit and inspections
o Dedicated circuit to the attic and (3) new duplex outlets
o Dedicated circuit to bathroom for a GFCI outlet
o Closet lights and switches
o Bath exhaust fan (fan only, no light)
o (1) shower recessed light and switch
o (1) medicine cabinet lighting
o Existing wiring will be used to the extent possible
o Light fixtures to be provided by customer
MISCELLANEOUS
o Install roof jack and make connection to new exhaust fan
o Install (1) recessed medicine cabinet above sink
o Site preparation and set -up
o Site breakdown and general cleaning
ITEMS PROVIDED BY CUSTOMER (Not included in contract)
o Shower pan
o Shower surround
o Medicine Cabinet
o All light fixtures
o All wall fixtures (toilet paper holder, towel rack, etc.)
o All plumbing fixtures
o Toilet (existing)
o Pedestal sink (existing)
o Doors (existing)
o Washer and dryer (existing)
o Windows (existing)
o Shower door assembly
•
DRYWALL
o Install ' /a" moisture resistant drywall in bathroom and utility area
o Install V2" drywall in bedroom closet area
o Tape and fmish all drywall
INSULATION
o Insulate wall between bathroom and bedroom using R13 fiberglass
o Inspect existing insulation for signs of mold and air infiltration
WINDOWS
o Remove and reinstall sash units for painter
DOORS
o Reinstall (3) existing doors including mortising hinges into new door jambs
CLOSETS
o Construct and install (2) sets of bi -fold doors at bedroom closet location
o Construct shelving (Design t.b.d.) in bedroom closet
o Install closet poles
o Install carpet in bedroom closet
o Construct and install shelving in utility room closet
SHOWER
o Set shower pan
o Install surround
o Install standard glass door assembly
WAINSCOTING
o Install approximately 30 lineal feet of pre -primed poplar wainscoting in bathroom area
o Install approximately 30 lineal feet of chair rail in bathroom area
FINISH
o Install all window and door casings using 1 x 4 pre- primed pine or colonial casing
o Install all window and door jambs using pre -primed pine
o Install all baseboard in bathroom, utility area, and bedroom closet / wall area
o Install all bathroom wall fixtures (toilet paper holder, towel racks, door stops, etc.)
FLOORING
o Install sheet linoleum flooring (Allowance for $2.00 / square foot)
ego BUILDERS
SCOPE OF WORK
March 13, 2011
CUSTOMER NAME: Dan & Carolyn Kibe
ADDRESS! 354 Bridge 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 Subcontractor oversight and management
o Materials ordering and delivery
o Certificate of Occupancy
DEMOLITION
o Disconnect and secure all plumbing fixtures including: Toilet, Shower, Washer, and Sink
o Remove and secure all items being saved (ie. Washer / dryer, toilet, sink, doors, etc.)
o Remove and dispose of all interior trim (baseboard, window and door casing / jambs, etc.)
o Remove and dispose of shower surround and pan
o Remove and dispose of selected drywall - - keep drywall that is intact
o Remove and dispose of wall separating bathroom and utility area
o Remove and dispose of shower wall
o Remove and dispose of various sections of wall between bedroom and bathroom
o Remove and dispose of subfloor and secondary floor (sleepers)
o Remove and dispose of utility room shelving
o Dumpster
FRAMING
o Inspect all existing framing for structural integrity
o Install sister joists and blocking to sure and level bathroom / utility area floor
o Install all fire blocking (including fire caulking) as required by local building code
o Relocate tub wall
o Install new wall connecting bathroom and bedroom
o Install new wall connecting utility area and bathroom
o Install new subfloor (5/8" plywood)
o Install strapping on ceiling joists (level ceiling)
o Frame new closet area in bedroom
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.
KEITER BUILDERS, INC. HOMEOWNER
03 —
by : o ' Keiter, its president Date Date
Date
6
WHICH HAS BEEN APPROVIED BY THE SECRETARY F THE EXECUTIVE OFFICE OF
CONSUMER AFFAIRS AND BUSINESS REGULATIONS THE CONSUMER SHALL BE
REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS,
C.142A.
i
KEITER BUILDERS, INC. HOMEOWNER
/,/ -i//... 03-J3 -11 G � _ 4.? "ire, i./
i t Scott Keiter, its president Date Date
c i „
L. )K)14. 3W1)
Date
NOTICE:
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO I THE AGREEMENT OF THE PARTIES
TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED 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 Agreeknent, 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 CANC EL 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.
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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
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
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
Steve Wilson, Electrician
Earl's Plumbing and Heating
S.T. Flooring, Inc.
A Brush Above, Painter
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,
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 180 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
Five Thousand, Two Hundred ($19,939.12) DOLLARS. Payments against work completed and materials
delivered will be 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) ($598.18)
33% of Total Price due prior to initiating work. ($6,579.91)
33% of Total Price due following rough inspections. ($6,579.91)
31% of Total Price due at Substantial Completion. ($6,181.12)
All sums not paid 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. feels 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- 2011), and License #102457 (Exp. 06 -20- 2012), is
entering into this Agreement with you Dan and Carolyn Kibe of 354 Bridge 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 354 Bridge 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 x Electrical Permit Smoke Certificate
x 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
- - - - - T CERTIFICATE OF LIABILITY INSURANCE I UN I C VIIMIUUIT T T TJ
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 certificate 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. PH N ,Exq: 413.586 F,vc,NO): 413. 586.6481
8 North King Street E -MAIL
ADDRESS:
Northampton, MA 01060 PRODUCER 00021099
CUSTOMER ID /_ . —,,. —_
INSURER(S) AFFORDING COVERAGE NAIC p
INSURED INSURER A: Travelers Casualty of America
- --------- --- --- - - -- - --
Keiter Builders, Inc. INSURER B: Travelers Companies, Inc.
51A Hatfield Street
INSURER C
Northampton, MA 01060 INSURERD:
- t
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 ADDL SUER POLICY EFF POLICY EXP F
LTR TYPE OF INSURANCE INSR W VD POLICY NUMBER ' LIMITS
[MMIDDIYYYI') {MM10D1YYYY)
GENERAL LIABILITY I6806319N661ACJ11 06/01/2011 06/01/2012 EACH OCCURRENCE $ 1,000,000
DAmA, E TO RENTED
X 1 CON1MERcIA.L GENERAL LIABILITY PREMISE • {Ea uCCUrrenrel I $ _ 300,000
r
L
1 CLAIMS-MADE r X OCCUR MED EYE' (Any one person) $ 5, 000
A PERSONAL & ADV INJURY $ 1,000,000
rENERAL AGGREGATE $ 2,000,000
k.
1 C -HIL AG +CPE=ATE LIMIT APPLIES PER PRODUCTS- COMPtOPAOG $ 2, 000, 000
FF.C1
1 1�'OLb.Y JFCT L +JC $
1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
i (Ea accident) $'
ANY AUTO
BODILY INJURY "Per person) $
1 ALL OWNED AUTOS
BODILY INJURY (Par aCodent) $
SCHEDULED AUTOS — — — - --- ----- ._ - ._... -
PROPERTY DAMAGE
r HIRED AUTOS 1 (Per accident) $
1 NON-OWNED AUTOS
1 $
UMBRELLA LIAB , ,rr IJR 1 EACH OCCURRENCE $
EXCESSLIAB - -- CLAIMS -MADE AGGREGATE $
1 DEDUCTIBLE
RETENTION $ 1
� WORKERS COMPENSATION 1 UB2A565782 0611112011 06/1112012 XI'
WC I � OTH
AND EMPLOYERS' LIABILITY Y 1 N _ — __ A T = R r LIIv1iTS1 ER
B NYIPR h I IETO R [ RTNER /EXECUTIVE I N� N E L EACH ACCIDENT $ 100,000
(Mandatory in NH) E. L DISEASE EA EMPLOYEE. $ 100,000
DESCRIPTION OF OPERATIONS below E.L DISEASE POLICY LIP IT 1
- . I $ 500, 000
DESCRIPTION OF OPERATIONS( LOCATIONS 1 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
tea- it
�40r../
For Information Only ""' Cynthia Henderson, CISR /CINDY
® 1988-2009 ACORD CORPORATION. All rights reserved.
The Commonwealth of Massachusetts
Jr,
Department of Industrial Accidents
' ` f ' Office of Investigations
{ ::: T i 7
i i i 600 Washington Street
,a' . ` . ic Boston, MA 02111
;_ www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): kF trd-,t. QvuLt ,4„ ., T:Nc.
Address: S i A 0A c qtE..t.-10 Ti".
City /State /Zip: Ivo etcyrf , vttA o toJDo Phone #: ‘7 - 3Zo - ,03..c
Are you an employer? Check the appropriate box: Type of project (required):
1. am a employer with 2_ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working employees and have workers'
g for me in any capacity. $ 9. ❑ Building addition
No workers' comp. insurance comp. insurance.
required.] 5. ❑ 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. ❑ Plumbing repairs or additions
myself. No workers' comp. right of exemption per MGL 12. ❑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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 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: 12hvEL. - ,S TnisQ,e,A..vC .
Policy # or Self -ins. Lic. #: U g. A 5 782 Expiration Date: Co- II — .2 o 1 Z
Job Site Address: &s9 IC.'D6E. S: City /State /Zip: v TDN 1 VA A c 1 o b 4)
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 DIA for insurance coverage verification.
I do hereby certif jfnd the ains /J and penalties of perjury that the informution provided above is true and correct
Signature: / /� I,�GSi�t.ml lt Date: 0/ - 01— / 2—
g /
Phone #:
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
Cuntuet Pureun: Phunv #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Sccerr Ve. tTEA_ /0•
License Number
5 I A TfIeLb ST. , No2Tw0evNQTbCJ , t"AA o 1'060 (o - 20 -col Z
A ddr s Expiration Date
W3 - 3 2 0 - 90s
ignatu a Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
f (d-, T &, /'-fls . . i (3 295
Company Name Registration Number
5) N - 14.4-rvtEtb ..w. , 3 -rdnt vues pt 060 do - 01 - z o t'S
Address Expiration Date
Telephone, '93 - 320 - 9
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 k_ 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) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [DI Decks [[] Siding [D] Other [L
Brief Description of Proposed
Work: 1•0■1 - F(2 ,iA �ErtAOD1C.l.. ~-
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
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 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 • lands? 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.
?LG.- A S fc. STrC Arrrfcc li• SIENeb Coa tAc-T
Signature of Owner Date
\<e' ��C -� , 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.
Sco7r Ke r TECZ_
Print Name
Pear 01 - 02 — 17.
Signatur f 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: 1; R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage mo
(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 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,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 0 NO
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
/
•
s
i
•
sT"
9.„„ \ City of Northampton Department use only
Status of Permit
Building Department Curb Cut/Driveway Permit
i n : 212 Main Street Sewer /Septic Availability
.,, ■ ;: Room 100 Water/Well Availability •
4/4 . • r Northampton, MA 01060 Two Sets of Structural Plans
#• . ' _ ` . $; one 413- 587 -1240 Fax 413- 587 -1272 Piot/Site Plans
4 6 ; . , Other Specify
e , '
4I N
ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
N.
•�/
SECTIO , - SITE INFORMATION
1.1 Property Address: This section to be completed by office
�AN t Clt2.oc..�N ICia :
35Y. St.././>6E ST. Map Lot Unit
Na`c nifiN i'ra Al AAA DID b o Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
DAN It CAQotTN k.toS 301 lN.r�FEST ) N 1"4AvorAi MA ototm
Name (Print) Current Mailing Address:
'=, 9/ 3 - s - 2.0 2
LE ••S E Pa -ITL4vG.1tEN, Contra 047 Telephone
Signature
2.2 Authorized Agent:
c. o r r t-tr.& 14 fre-2 C3tmaticeit o Stec. .5 I A W-A•f 1 Et..rb ST , 11/4 A1"t+Aw4Tax.1 r 64. c"ot. e,
•
Na (Prin Current Mailing Address:
� n
‘a-St gig - 320 - 9031
ignature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / 2 (a) Building Permit Fee
39.ia.
2. Electrical I /, 2 o O (b) Estimated Total Cost of
Construction from (6)
3. Plumbing $ 5 . O Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 4 /1 1z— Check Number _) 0 g _ 17/1 This Section For Official Use Only V
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0622
APPLICANT /CONTACT PERSON SCOTT KEITER
ADDRESS /PHONE 51B HATFIELD ST NORTHAMPTON (413) 320 -9035
PROPERTY LOCATION 354 BRIDGE ST
MAP 25A PARCEL 095 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 07c0 � 7 _ //7
Fee Paid /
Typeof Construction: REMODEL BATHROOM /LAUNDRY ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102457
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INOIFMATION PRESENTED:
V F�
Approved _ _ Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site 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
7 e_ ay
/ y-/ ---
ature o Bhilding ! ' icial 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 40A. Contact Office of
Planning & Development for more information.
354 BRIDGE ST BP- 2012 -0622
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 095 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- 2012 -0622
Project # JS- 2012- 001072
Est. Cost: $19939.00
Fee: $119.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT KEITER 102457
Lot Size(sq. ft.): 14810.40 Owner: KIBE DANIEL E & CAROLYN Y
Zoning: URB(100)/ Applicant: SCOTT KEITER
AT: 354 BRIDGE ST
Applicant Address: Phone: Insurance:
51B HATFIELD ST (413) 320 -9035
NORTHAM PTON MAO1060 ISSUED ON:1/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM /LAUNDRY ROOM
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 1/5/2012 0:00:00 $119.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner