25-070 ACORD DATE am
I CERTIFICATE OF LIABILITY INSURANCE 03 /09 /2010
PRODUCER 413.586.0111 FAX 413.586.6481 THIS CERTIFK:ATE IS ISSUED AS A MATTER OF INFORMATION
Webber & Grinnell Ins. Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
8 North King Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
Northampton, MA 01060
INSURERS AFFORDING COVERAGE NAIC #
INSURED Scott Keiter INSURER A: Travelers Casualty of America
DBA: Keiter Builders INSURER B: WCAR- Liberty Mutual
51B Hatfield Street INSURER c
Northampton, MA 01060 INSURER D:
INSURER E
COVERAGES
THE POUCIES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INFR ADM TYPE OF INSURANCE POLICY NUMBER DA (aMD0 YYYY) �
RR IN p Y LIMITS
GENERAL LIABILITY 6806319N661AC709 06/01/2009 06/01/2010 FALCHOCCURRacE $ 1,000,000
DAMAGE 10 X COMdERCIAL GENERAL LIABf.ITY PREMISES ( Ea occurrrrence) $ 300,000
1 CLAIMS MADE X ( occUR M_D EKP (My one person) $ 5,000
A PERSONAL & ADV INJURY $ 1,000
GENERAL AGGREGATE _ $ 2,000,000
GENE AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
— 1 POLICY [1 n LOC
AU,CMOOLELIAB.nY COMBINED SINGLE LIMIT
ANY ALTO (Ea B s
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
Nov -OWNED AUTOS
- BODILY
acadert)
PROPERTY DAMAGE
(Per accident)
GARAGEUABLITY AUTO ONLY - EA ACCIDENT $
ANY AUTO INHERIT-IAN
TFIAN EA ACC $
AUTO ONLY: AGG $
EXCESS /u MBREL EACH OCCURRENCE $
( OCCUR ( ( CLAIMS MADE AGGREGATE _ $
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WC231S376387010 03/05/2010 03/05/2011 ' y,!m t 1
AND EMPLOYERS' uasLny
B A ERAD< CUI1VE ( Yt i EL EACH ACCIDENT $ 100,000
(Mandatory In Mt YES EL DISEASE - EA EMPLOYEE $ 100,000
If yes. describe under
SPECIAL PROVISIONS be E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES 'EXCLUSIONS ADDED BYEICORSi IT! SPECIAL PROVE
The Workers Compensation policy does not provide coverage for Scott Keiter.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPRATION
DATE THEREOF, THE ISSUING INSURER WLL ENDEAVOR TO MAL DAYS WRITTEN
NOTICE TO THE C RTIRCATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SO SHALL
MOSE NO OBLIGATION OR UABLITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
= B * * For Informational Purposes Onl y r * * = * AUTHORIZED REPRESENTATIVE
Cynthia Henderson/CINDY
ACORD 25 (2009/01) M 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
CONTRACTOR'S LIMITED WARRANTY
KEITER BUILDERS
51B Hatfield St.
Northampton, MA 01060
Phone: 413 - 320 -9035
Fax: 413 - 586 -1890
The contractor signatory below Scott Keiter ( "Contractor ") hereby guarantees Danielle Crescione
( "Owner ") that the construction performed on that certain structure located at 43 Riverbank
Road, Northampton, MA to be free from defects in material and 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.
1 ` 0 1;,:20/ 6
Sig : e Date
® KEIVER
BUILDERS 51B Hatfield Street •Northampton•MA•01060•Phone: 413 - 320- 9035•Fax: 413 - 586- 1890•keiterbuilders.com
SCOPE OF WORK
May 08, 2010
CUSTOMER NAME: Danielle Crescione
ADDRESS: 43 Riverbank Road
Northampton, MA 01060
PHONE: 413 - 437 -4829
• Dismantle and dispose of front porch and wood shed on side of house
• Perform necessary roof repairs where front porch is attached to house
• Review condition of concrete steps to verify that they are suitable for use
• Mount (1) black anodized metal railing on concrete steps
• Cut -back copper water line and install new exterior water valve
• Clean debris from area and cover ground with high- powered magnet
NOTES:
• Contract includes building permit for demolition
• Customer to provide dumpster
• Contract does not include any work to be performed on concrete steps
• Contract includes minor roof repairs only
• Contract does not include any repair to fascia or surrounding trim
• Contract does not include any work on gutters
• Contract does not include any electrical work
Warranty
• Please see the attached document "Contractors Warranty"
Permits and Inspections
• All applicable permits will be handled by Keiter Builders
• All building inspections will be scheduled by Keiter Builders
TOTAL PRICE FOR ALL LABOR / MATERIAL: $1,750
NOT SEPARA'T'ELY 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. I 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.
KEITER BUILDERS HOMEOWNER
/ 1
.J _ / OS 0
� .101 b i0
q,
Scott Biter, its owner / Date / Date
Date
5
obligations under this Agreement, then I 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 I may have incurred or might
incur in good faith in connections with this Agreement, as well as receiving payment for my 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:
I will grant you, as part of the Total Price, a Limited Warranty, a copy of which is attached to this Agreement. I
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
REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS,
C.142A.
KEITE ' : UILDERS HOMEOWNER
N.
f/ . / A. D( O , O (--- ,c)/ / v
B . colt Keiter, its owner 1 D ate Date
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
4
I MAY NOT REQUIRE YOU TO PAY PART OR ALL OF THE BALANCE NOT YET DUE UNDER
THIS AGREEMENT BECAUSE I DEEM MYSELF TO BE INSECURE. HOWEVER, IF I DEEM
MYSELF TO BE INSECURE, I MAY REQUIRE AS 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 MY SIGNATURE FOR ANY WITHDRAWAL.
SUBCONTRACTORS:
I intend to hire the following subcontractors to assist me in the work:
Name
N/A
These may not be all the subcontractors that I may hire, and I may decide not to hire any one or all of the above
subcontractors, which decision shall be at my sole discretion.
If you ask any subcontractor to make any changes or substitute materials without first obtaining my 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 me the additional
cost any subcontractor charges me for- such changes -- and substitutions, and for any extra work and material
related to your request, plus Fifty (50 %) percent.
INSURANCE:
I 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 me 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
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 I 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 me feel insecure, or if you should commit a material breach of any of your responsibilities or
3
STARTING AND ENDING DATES:
I will apply for the permits within 7 day(s) of our signing this Agreement or your satisfying any conditions
required to be met prior to the permits being used, whichever date is later. I will start work within 30 day(s) of
obtaining the necessary permits and I expect to have the work substantially completed within 10 day (s) of
starting.
If I am 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 I may reasonably
extend the date for substantial completion. If the work is not substantially complete by the ending date, as
extended, I 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, I 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
One-thousand, seven -hundred -and fifty -(S1,750) - DOLLARS Payments against work completed - and materials
delivered will be made within 2 days from when I tell you that I have reached different completion stages.
Payments will be made in the amounts as set forth below.
'/2 of Total Price made prior to work being started ($875.00)
'/2 of Total Price made upon substantial completion of work ($875.00)
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 I incur 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 I may immediately stop work. I may choose to not
start work again until you are current with the payments and I feel secure in obtaining the remaining payments.
If there is any stoppage in work due to your failure to pay on time, or to make me 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.
2
CONSTRUCTION AGREEMENT
I, Scott Keiter owner of Keiter Builders, of Northampton, MA whose Federal Tax Identification Number is
26- 4579629, Contractor's Registration Number 163295 (Exp. 06 -01- 2011), and License #102457 (Exp. 06 -20-
2012), am entering into this Agreement with you Danielle Crescione of 43 Riverbank Road, 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:
I will perform the work set forth in the attached Scope of Work on your home, or the property located at
43 Riverbank Road, 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. I reserve
the right to make minor changes in any plans and to substitute materials of equal or better quality.
Should I 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 me 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, I, or subcontractors I hire, will obtain, on your behalf, the following permits
(if required):
x Building Permit Electrical Permit Smoke Certificate
Plumbing Permit x Demolition Permit Certificate of Occupancy
IT IS MY OBLIGATION TO OBTAIN THESE PERMITS AS YOUR AGENT. IN THE EVENT THAT
I DO NOT OBTAIN THESE PERMITS, AND YOU OBTAIN THEM, OR IF I AM 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.
My obligation to obtain permits is limited to those permits directly related to performing the work I agree 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 of conservation commissions, are
required to be obtained before I can obtain my permits, it is your obligation to satisfy such requirements and
you shall meet those requirements at your cost.
K1EITER
BUILDERS
CONSTRUCTION AGREEMENT
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own'constructron supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
•ermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
l; understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
. ... • . .„ 7.
• ,
. The Commonwealth of Massachusetts
Department of Industrial Accidents •
s o, ........ms.i.■ ll
5' E fill 1.1. .:1 Office of Investigations •
111 = am 1=1: t
=r1VIA= 600 Washington Street
,.*
• ee Ai v-- Boston, MA 02111
I-... =T.-L-3F
*-....A;■"" - I www.mass.gov/dia
• __..
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly -'
Name (Business/Organization/Individnn1): V& 1 1-- 67k. OU1 L_I)Cvf C ('co 77
- Address: .5 8 t-letzc(e- L.- -7' A JO --a- TZ) Al , M
i 1
City/State/Zip: i•-id 1 - ntec - /A-i- c - r`--) Phone.#: / (3 - 32 , D - Tos
.
Are you an employer? Check the appropriate box: Type of project (required): /
1. I am a employer with 4• 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. 0 Remodeling
2. a sole proprietor or partner-
ship and have no e1oyees These sub-contractors have . 8. Demolition
working for me in any capacity. w and have workers' -
9. Building addition
[Na workers' comp. instriance _ comp._insurance.t: . •
10.0 Electdcal repairs or additions
0 We are a corporation and its
3. 0 I am a homeowner doing all work officers havetxercised their .
I. 11.0 Plumbing repairs or additions
myself [No workers' comp. right Of exemption per MGL
12.0 Roof repairs . •
insurance required.) t ' c. 152, § 1(4), and we have no
ernployees. [No workers' 13.0 Other
• comp. insurance reqUired.1 .
*My applicant that checks box #1 must also ffil out the section below showing theirworkers compensation policy information.
t Homeowners who submit this affidavit inthcating they are doing all work and then hire outside contractors must submit anew 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 cavities have
employees. If the sub-contractors have mnployeeSohey must pnlvide their workers' comp policy number.
lam an employer that is providing workers' compensation insurance for my einployees. Below is the Policy and job site
information. •
Insurance Company Name: • . • .
Policy # or Self-ins. Lic. #: Expiration Date:
•
. .
Job Site Address: City/Stair/Zip:* - -
Attach a copy of the workers' compensation policy declaration page (showing the policy nuinber and expiration date).
Failure to secure coverage as required tinder Section 25A ofMGL c. 152 can lead to the imposition of penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to S250.00 a day g `.. the violator. Be advised 'that a copy of tbis statement may be forcird to the Office of
ons .. 7 P • • for initriarke - eo Veraie liiii.fiCition. _ . _ - . ... _.: , — . ,_ „, ,
_ rdo herekVce ,, nder the enalties ofperjray that the mformationprovided _andeorrprt
--, Signature: , if
) ,----- Date: e2.5 f .-- T ° • -.
- ,
Phone 4: / ,!Z ? --: 32O - cb 3 -V - ' .
. - Official use only. Do not write in this area, to be completed by city or town'officifif
• City or Town:
Permit/License #
Issuing Authority (circle one): ' .
•
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: . . .
1
SECTION 8 - -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S co 7T
License Number
� I l '� l ELl) S r. N-4 `iii - N to - L 0 -2_01
Addres 4e. Expiration Date
• lure Telephone
9:'Re4istere l oitir lmtarOVettien tit[ftiars>tbr .;
itozi ' « ati . Not Applicable ❑
J(E < a I L1 S I (= 3;235
Company Name Registration Number
S fg I �t £-�-� S ?. e 01 D if
Address Expiration Date
\IQ'CJ tflAyr0 /J M- Telephone ..32-0 - 90 )
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(8))
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 ❑
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
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) [J Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition Aft, New Signs [0] Decks [E3 Siding [0] Other [0]
"Work: Description of Proposed , - r rr
Work: �°�� ax ! -flu � ?d.rC Yl L„-JOa
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a If Ouse and ora dit Eo xisti q sr _ ncompl t+ the foIJo v n :
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 wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth 9(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 la'- 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.
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 pennall ies of
_ e
Print Name ��
•
/ /� ()5 ) D 1
Signatur "V ner /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 I
Frontage 1 1 i 1 ,
Setbacks Front t 1 1 1 i
Side L:i I R:= i L:1 ` R: .._..: i j
Rear = 1 1
Building Height I j i i i
Bldg. Square Footage r i 1 1% i 1 1 I
Open Space Footage % €
(Lot area minus bldg & paved l, * i..? 1 , 0 _ 1 i
parking)
# of Parking Spaces i i i
Fill: „.,., m.,.. ._.. i ._
(volume & Location) i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
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 Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
i
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 0
IF YES, describe size, type and location: I �
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
h
City of Northampton `' t
Building Department Atm is;
212 Main Street
-Room 100 ®i � 4 , 17 �
Northampton, MA 01060
phone 413- 587 -1240 Fax 413 - 587 -1272 �� `` `
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
Y3 Live-it i3 flrti 7 j Map , Lot � � � �. klnif
�1 c vi'T7-Fr4vt.0 yv' u M Zone„ Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
E Li E CV- E. CiOki
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: //
C.c u H r T'- ,2 11,9-7 E4 S 7 Yz 3 0 t "
Name (Print) Current Mailing Address:
W3- 32_° 503 s
Signature Telephone
SECTION - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building i y U (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) C Number ' 35--
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
))0 407c e).1S ! ,f: '�T 'e2 &L/1l( S /de frVe'oGY Sf�–Gt
0 C�r1( vt � C -i vLC'-{ d �-. w �;�.z t h s e r/
� S 1A-cOa
•
File # BP- 2010 -0998
APPLICANT /CONTACT PERSON SCOTT KEITER
ADDRESS/PHONE 51B HATFIELD ST NORTHAMPTON (413) 320 -9035
PROPERTY LOCATION 43 RIVERBANK RD
MAP 25 PARCEL 070 001 ZONE SC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid / lek �f �,�/�
7 e"u
Tvpeof Construction:_DEMOLISH FRONT PORCH & SHED
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
INFORMATION 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
3 // 0
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.
43 RIVERBANK RD f . BP -2010 -0998
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25 - 070 . CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERIVIIT
Permit # BP- 2010 -0998
Project # JS- 2010 - 001466
Est. Cost: $1750.00 '
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT KEITER 102457
Lot Size(sq. ft.): 11543.40 Owner: CRESCIONE DANIELLE
Zoning: S CY 1001/ Applicant: SCOTT KEITER
AT: 43 RIVERBANK RD
Applicant Address: Phone: Insurance:
51B HATFIELD ST (413) 320 -9035
NORTHAMPTONMA01060 ISSUED ON:5/13/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMOLISH FRONT PORCH & SHED
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: Q(S; (bA) / (0 Lo tt( l
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. i+ou4
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/13/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo