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32A-079 (2) ACOR CERTIFICATE OF LIABILITY INSURANCE odioziz o ) ,RODUCER (413) 586 -0111 FAX (413) 586 -6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Gri nnel 1 Ins . Agency, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 North Kin Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Northampton, MA 01060 INSURERS AFFORDING COVERAGE NAIC # NSURED Scott Keiter INSURER A: Travelers Companies, Inc. DBA: Keiter Builders INSURER B: 351 Pleasant Street Ste 147 INSURER C: Northampton, MA 01060 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR DD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS 4Rfl DATF fMM /DDIYY1 DATF IMM /DD/YYl GENERAL LIABILITY APP /BOP 06/01/2009 06/01/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 PRFMLCFR (Fa nrri irenrP) CLAIMS MADE I X OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 n POLICY n .7118i n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY (Per accident) $ NON -OWNED AUTOS I PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ I $ WORKERS COMPENSATION AND I TC1RY IM TC I I EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below Et DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. -- For Informational Purposes --- AUTHORIZED REPRESENTATIVE �) Cynthia Henderson /CINDY f � ACORD 25 (2001/08) ©ACORD CORPORATION 1988 • CONTRACTOR'S WARRANTY KEITER BUILDERS 351 Pleasant Street, Suite 147 Northampton, MA 01060 Phone: 413 - 320 -9035 Fax: 413 -586 -1890 The contractor signatory below Scott Keiter ( "Contractor ") hereby guarantees Joe Debic & Casey Smith ( "Owners ") that the construction performed on that certain structure located at 30B Graves Ave., Northampton, MA be free from defects in material and workmanship for a period of one 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. ?. 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. ./ / /\,/ '7 / — 7 _ Ici 9 2 -0 q S i g fu r-; r + Date 1 , KEITER BUILDERS 351 Pleasant Street, Suite 147 Northampton, MA 01060 Phone: 413- 320 -9035 Fax: 413 -586 -1890 CUSTOMER NAME: Joe Debic & Casey Smith ADDRESS: 30B Graves Ave. Northampton, MA 01060 SCOPE OF WORK: Properly ventilate both bathroom fans and dryer to exterior of home. 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 iff e- by, Scot eiter, it owner Date Date { / , "1� 7 f ate 6 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 BUJLDERS HOMEOWNER / L 1 f By Sco Keiter, its owner Date Date ( r ,, G' i 1 1 f,./( --/ 1 i JJ i + ) t C l',./ (2/0‘f 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 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. 5 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 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 4 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. 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: 1 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. 3 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. STARTING AND ENDING DATES: I will apply for the permits within N/A 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 N/A day(s) of obtaining the necessary permits and I expect to have the work substantially completed within 7 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 d 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, two hundred and fifty ($450) 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. '/Z of Total Price made prior to work being started ($225.00) '/Z of Total Price made upon substantial completion of work ($225.00) 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 which ever 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. 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 Joe Debic & Casey Smith of 30B Graves Ave., 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 30B Graves Ave., 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 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. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees_ Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work rmtil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' romp nsation affidavit_completely -y checking- the- box-es -taata or - situation and; if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of • Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self - insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pernutilicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write . "all •locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year Where a home owner or citizen is,obtain pg a license or permit not related to.anybusiness or_commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit..:.. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to ive us: a call. - -- The Department's address, telephone and fax number. The Commonwealth of Massachusetts - Department of industrial Accidents OfBee of Inve igations 600 Washington Street . Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877- IvfASSAFE Fax # 617 -727 -7749 Revised 11 -22 -06 www.mass_gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents =1 �� Office of Investigations ° -�� 600 Washington Street : =IV= Boston, MA OZIII www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): <.t ii fL 151.)1 L D N C., C 0 Address: 35/ Pl .„.mi t f 1T / t7 City /State /Zip: N6t27Ft7wt P 17A) Llf ()t0 bn Phone. #: 1 /13 - 320 7b3 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have. no Pnployees These sub - contractors have g, ❑ Demolition working _forme in any _ ca aci employees and have workers' P ty $ 9. ❑ Building addition No workers' comp. insurance comp. insurance. re ed 5. We are a corporation and its 10.0 Electrical repairs or additions ffi h id their ] officers have exercseer . 11. Plumbing repairs 3. ❑ I am a homeowner doing all work ❑ g ep irs 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 employees. [No workers' 13.0 Other comp. insurance required.] *My 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. xContractors 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: 30 ' C? 2-A trc j - V City /State /ZipM t Pre'tJ /(,t: ii, ti 060 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage . as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 Ene 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: ce C ' and a pains and penalties of perjury that the infornation provided .above _is_true- aruLcorrecL ..._..: Signature: � G _ p ate: /0 25 .07 • Phone #: 03' 32o -(7035 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 #: .,. 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 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 1, , as Owner /Authorized Agent hereby de re 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 p; al • ,•-rjury. Print Name / Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : S taZTT VE / i L / C1 - S S 7 License Number e - s ,■Jeti A- ET ti1A C2720/2-012_ Address Expiration Date 9/3 WD Signatu 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 building permit. Signed Affidavit Attached Yes 0 No 0 Sv�-E �Q� t Q AAp Loyet-s 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 /� SC CT f � f MIL t30 /GAS Not Applicable ❑ Company Name: 4{e-rTz Responsible In Charge of Construction .57 e E-1_ 1) Sr , f/pn iAg -)TD!V j'77 4- Address 326 °y03 S� Si. ' ' Telephone Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Ls Interior Alterations C 7' Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration 12I Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. .JS — V i l t- Ar'£ tQ e2 `t. OO NI Of Proposed Work: TD 2 FA&E V ‘g& R o C M p 7 or.J SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1 -2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 0 R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ( ❑ 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 1 st 2nd 2nd 3rd 3rd 4 4th 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 Zone❑ Municipal ❑ On site disposal system 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 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 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 �_ v \\ \i � ' : Department use only \ 'Ln � ': r- -- - City Northampton Status of Permit: 7 r-- Buil g Department Curb Cut/Driveway Permit _ ` s ri ; 212 Main Street Sewer /Septic Availability Rootn 100 Water/Well Availability 11 o'i am , MA 01060 Two Sets of Structural Plans pt g - 1240 Fax 413 - 587 - 1272 Piot/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 1.1 Property Address: This section to be completed by office 30a Giz au A:)E. Map 3xy Lot - (/ Unit N O R_T-A R TaN i IMfA 10 G Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 'ttS iE Srt,1/4- 11 30 i3 F3 otKes A L£ Name (Print) Current Mailing Address: 7 /V- 7 /Y_ e/ 9 Signature -PL-EA se 5 -t C Telephone 2.2 Authorized Agent: C.csTT Ve I —2_ , 6 r & RA 16 s7 Name (Print) Current Mailing Address: /V 0 a77 ,O Tail( 4 OA A / `I i 3 -- 32_ a ° �'a3� Signature -.. t /' ..� Telephone SECTION 3 - ES I ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building P LIS (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 /a0 7 If S‘" This Section For Official Use Only Budding Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0441 APPLICANT /CONTACT PERSON SCOTT KEITER ADDRESS /PHONE 51B HATFIELD ST NORTHAMPTON (413) 320 -9035 PROPERTY LOCATION 30B GRAVES AVE MAP 32A PARCEL 079 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid /06? (1"56— _ Typeof Construction: VENTILATE DRYER & BATHROOMS TO EXTERIOR 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 v' / 2 o. 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. X9 3_1.0 t am ,...1:2r 114 ''-1r t i- -/- n ..w+o- r" , NO I_\- 0 L e c to we t om , r'% -"1_) SN -, A pu t 0 1 - 'v c a mot/ y� (kv - c=' .i___i -)y Z) - Q1 _3 » I \ -- 7 -1-77— , - ..___ _ c . L,..7.7 --7i.-&\?0,.) ,,,.4- r 7: 7 7 \-4 ..... --- itA --1-4, 3013 GRAVES AVE BP- 2010 -0441 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 079 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP -2010 -0441 Project # JS- 2010 - 000597 Est. Cost: S450.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 1 of Size(sq. ft.): Owner: SMITH CASIE Zoning: URC Applicant: SCOTT KEITER AT: 0. GRAVFS AVF Applicant Address: Phone: Insurance: 51B HATFIELD ST (413) 320 - 9035 NORTHAMPTONMA01060 ISSUED ON :10/23/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK VENTILATE DRYER & BATHROOMS TO EXTERIOR 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: Inseolation: Final: Smoke: Final: ©K THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. y , Certificate of Occu •anc 1V '! Si. nature: FeeType: Date P. id: Amount: Building 10/23/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 24 -30B GRAVES AVE BP -2009 -0805 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 079 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: chimney rebuild BUILDING PERMIT Permit # BP- 2009 -0805 Project # JS- 2009 - 001203 Est. Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: . TOGNARELLI HEATING & COOLING 68021 Lot Size(sq. ft.): Owner: HODGES ENTERPRISES LLC C/O BELLENDEN RAND HUTCHESON Zonintl: URC Applicant: TOGNARELLI HEATING & COOLING AT: 2 -3 ti (R Applicant Address: Phone: Insurance: 123 AVENUE A (413) 863 -2295 Workers Compensation TURNERS FALLSMA01376 ISSUED ON :4/13/2009 0:00:00 TO PERFORM THE FOLLOWING WORK :RELINE CHIMNEY, MUST HAVE LINER INSPECTED BEFORE APPLIANCES ARE CONNECTED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector uf Plumbing " inspector otWiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: - Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: erft o 4 /i31 c ! [ +,/ 1 S Rough: Oil: Insulation: Final: Smoke: Final: 0, ( r ► . THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 4 -, -.k . if Certificate of r ey Signature: FeeType :, ,. - - Date Paid: Amount: Building 4/13/2009 0:00:00 $55.008788 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 24 -30B GRAVES AVE BP- 2009-0804 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 079 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2009 -0804 Project # JS- 2009 - 001203 Est. Cost: $750.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TOGNARELLI HEATING & COOLING 68021 Lot Size(sq. ft.): Owner: HODGES ENTERPRISES LLC C/O BELLENDEN RAND HUTCHESON Zonin URC A 4)J4i R' TOGNAREL.. l HEATING & COOLING AT 24 -30B GRAVES AVE -- Applicant Address: Phone: Insurance: 123 AVENUE A (413) 863 -2295 Workers Compensation TURNERS FALLSMA01376 ISSUED ON:4/13/2009 0:00:00 TO PERFORM THE FOLLOWING WORK :RELINE CHIMNEY, MUST HAVE LINER INSTPECTED BEFORE APPLIANCES ARE CONNECTED 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: OK Gas: Fire Department Fireplace /Chimney: C 1131 6 9 (04.4 Is Rough: Oil: Insulation: Final: Smoke: Final: il 'a, THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. '" Certificate of Occupancy p Signature: FeeType: Dat Paid: Amount: Building 4/13/2009 0:00:00 $55.008787 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo