22B-040 (2) L
ARBITRATION: - - _ _
THE CONTRACT AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT
IN THE EVENT THE CONTRACTOR HAS A DISUPUTE CONCERNING THIS CONTRACT, THE
CONTRACT 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 REQUIRED TO
SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A.
KEITER B : LDERS HOMEOWNER
i Og--)g-07 ■ it% L
t
By S • • Keiter, its owner Date ate
Date
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO 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 AL "I'ERNATWE 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.
5 .
The Commonwealth of Massachusetts
dmm` Department of Industrial Accidents
Office of Investigations
=a Tr 1 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information y�� Please Print Legibly
Name ( Business /Organization/Individual): --� T =i!�. go I` 1.-bee 5 _
Address: S 6 fo" 6L-? U
Cit /State /Zip: A fie �/J Oka' Phone #: 1 f 3 ' 0 5 7 �
Are you an employer? Check the appr4priate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. New construction
2. m a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub contractors have 8. ❑ Demolition
capacity. employees and have workers'
working for me in any P ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
1. 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:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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 5250.00 a day against . e - kiolator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fo .s ance coverage verification.
I do hereby certify under „ an nal ' s of perjury that the information provided above is true and correct.
Signature: Date: Og 2A 69
Phone #: Lj(3 r 37---c 96 35 1
Official use only. Du 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 #:
,
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Signature of Owner Date
I, , 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.
Print Name .__,_. _ E,_,..,.._. _
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervisor Not Applicable ❑
Name of License Holder : w.. _. ke r T-E e ._. /Q
License Number
. 13 _ / lii r f 1(.L . - -, .. �i t ?_ N.tZ 1_,Mft._ ,_... _ ......c.. ,2 -c)../ .. '2- c _
Address Expiration Date
4/(3 3 L
p - qo 3S, _. .
Signat Telephone
SECTION 13 - 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 b ilding permit.
Signed Affidavit Attached Yes , ®, No
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
�eL fT
Responsible In Charge of Construction
_.!Jr .._ . —% sue .. ........ .. .......„ .,.,._... _,...._,_ _,., ..._.._.._ .. .
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size .
Frontage
Setbacks Front
Side
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 Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
W YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. • .
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs [iit Demolition 0 Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. C Q_E:A O ASS " .ct.. .. I A T'n c. J
Of Proposed Work: �N,�IL L
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 0
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational 0 2B .. [ ❑
F Factory ❑ F -1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ I -1 ❑ I -2 ❑ 1 -3 ❑ , 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): ___< Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 15
2"d 2nd
3 d . .. ...r... _��._ . _._r_.__ ____ ..._ 3 ro
4
( ) p
Total Area sf Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone0 Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit
Buil Departm Cu G�f/riuew Pefr
212 Main Stre ent T Sew u o er /S ifa bil i ty -
Room ding 100 Water) Welf
0 Northampton, MA 01060 Avallabtlity
`� Two Set of Str Pl
r,A5 phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Site.Plans
Other Specify .
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
(Zc) t/' `tO
Zone Overlay District
'F' ;0 —ENGC , (\A6-
..... w _ Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name (Print) g Address: Y
Current Mailing
Signature /_i i2 _ Telephone
SECTION 3 - E . ATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
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) Check Number Q� 1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0225
APPLICANT /CONTACT PERSON SCOTT KEITER
ADDRESS /PHONE 51B HATFIELD ST NORTHAMPTON (413) 320 -9035
PROPERTY LOCATION 221 PINE ST - UNIT 408
MAP 22B PARCEL 040 001 ZONE SI(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out //
Fee Paid (Df 6J
Typeof Construction: CONSTRUCT PAS THROUGH IN PARTITION WALL
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
INF ATION PRESENTED:
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
/ Demolition Delay
Signature of Building Official, 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.
221 PINE ST - UNIT 408 BP -2010 -0225
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22B - 040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP -2010 -0225
Project # JS- 2010 - 000263
Est. Cost: $1250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT KEITER 102457
Lot Size(sq. ft.): 145926.00 Owner: BRUSH WORKS THE LLC
Zoning: SI(100) / /WP Applicant: SCOTT KEITER
AT: 221 PINE ST - UNIT 408
Applicant Address: � Phone: Insurance:
51B HATFIELD ST (413) 320 - 9035
NORTHAMPTONMA01060 ISSUED ON :8/31/2009 0:00:00
TO PERFORM THE FOLLOWING WORK :CONSTRUCT PASS THROUGH IN PARTITION
WALL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
O Footings:
Rough: Rough: f//47 r" House # Foundation:
Driveway Final:
Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Gil: Insulation:
Final: Smoke: Final :(7f \ q-/v- d I „l /y'
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU : IONS.
Certificate of Occu • anc r ig sonature:
FeeTvpe: Date Paid: Amount:
Building 8/31/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo