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30B-058 (3) BUILDERS SCOPE OF WORK October 31, 2012 CUSTOMER NAME: Susan DeMaria ADDRESS: 147 Riverside Drive Northampton, MA 01060 PROJECT ADDRESS: 147 Riverside Drive Northampton, MA 01060 ESTIMATED START DATE: December, 2012 ESTIMATED PROJECT RUN TIME: 3 — 4 Days ADMINISTRATION • Keiter Builders, Inc. will manage the following aspects of the project: o Building permit application o Standing all necessary inspections o Materials ordering and delivery o Site set -up and break -down o Certificate of Occupancy WINDOWS THIS CONTRACT INCLUDES TLIE FOLLOWING: o All window specifications as shown in Andersen Window Quote # 3682 o Demolition and removal of (14) existing window units and storm windows o Installation of (13) Andersen Woodright double -hung inserts and (1) Andersen Woodright New Construction Awning Unit o All interior and exterior trim for the Awning unit Di' es ,to o All caulking, insulation, and miscellaneous stop molding for (13) insert units wa 61,1 o Installation will meet all manufacturer specifications. In 5' 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. By signing this Agreement, you acknowledge that you have received a complete and original signed copy of the entire Agreement and attached Exhibits. Keiter Builders, Inc. may not start work until after this Agreement has been signed DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS IS A LEGALLY BINDING AGREEMENT. IF THERE ARE ANY PROVISIONS WHICH YOU DO NOT UNDERSTAND, YOU SHOULD CONSULT WITH AN ATTORNEY BEFORE SIGNING. KEITER BUILDERS, INC. HOMEOWNER i by, ott eiter, its president Date Date Date 5 - -" CERTIFICATE OF LIABILITY INSURANCE 1 U "" `mm'UU'r rr}1 06/01/2012 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. H ONE 413.586 0111 7FaX 413 AIC No. Ext). 8 North King Street E-MAIL ADDRESS;_ -. Northampton, MA 01060 PRODUCER 00021099 CUSTOMER ID a: _ INSURER(S) AFFORDING COVERAGE NAIC R INSURED INSURERA: Travel Casualty of America Keiter Builders, Inc. INSURERS: Travelers Indemn. Co. CT 25682 51A Hatfield Street INSURER C : Northampton, MA 01060 INSURERD. INSURER E ' INSURER F : COVERAGES CERTIFICATE NUMBER: Master Exp 06/13 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 SUBRI i POLICY EFF POLICY fl' ; `M' LTR TYPE OF INSURANCE INSR i WVD I POLICY NUMBER , (MMIDDI1� I (MMIDDNYYY) , LIMITS GENERAL LIABILITY ! I 06/01/2013 , I: 1 ( 1, 000 , 000 I6 0 319 lA Z 0 1201 X _. eu 300,000 _ s 5,000 A 1000000 ..t - ? 2,000,000 F t 2,000,000 AUTOMOBILE LIABILITY I - , r :,_L t . . . . . _ . - ' I ' . , _ , F _ -,. l r { F E E UMBRELLA LIAB - _ - - - - :i: EXCESS LIAB - - -_TF - - -- I r , WORKERS COMPENSATION IEUB2A56S78212! 0611112012 l 06/11/2013 i 1 I " � AND EMPLOYERS LIABILITY YIN ; 1 I T r _ L I L I I E = 100,000 -11 pl ETA f-1 f q �.- 1 L F� It -IiT T B - c E E „L {s [ t NIA L _ i (Mandatory j 1- 100, 000 M m NH ` - 1= _ —__— t nF Ill�,1 I I rl,_�I �; rE_ L1 L r I L!•_ L 500,000 I DESCRIPTION OF OPERATIONS 1 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 r e.: it '' '' For Information Only ''' Cynthia Henderson, CISR /CINDY "�d�e./ © 1988-2009 ACORD CORPORATION. All rights reserved. P. The Commonwealth of Massachusetts Print Form , Department of Industrial Accidents '" -,--,,� ..— ; Office of Investigations ' ' 1 "! 1 Congress Street, Suite 100 /, l Boston, MA 02114 -2017 ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information // �� Please Print Legibly Name ( Business /Organization/Individual): /4 tre-z'1 E --1 S , ..L" c Address: 5) A• iii3TFiC :ST' City /State /Zip: /Aort't rb Ai ) item n /06 Phone #: G1/3 • ,s - 5' 6OC) Are you an employer? Check the appropriate box: Type of project (required): 1,JI am a employer with ....3 4. 0 1 am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. 0 New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' g Y P h 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.0 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 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. 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I, t tcG (S -_,46-c.,44"4, (E. _ Policy # or Self -ins. Lic. #: .Z: £ u AS i o 5 7 S ' 2 I Z Expiration Date: 6 -- I t – r 3 Job Site Address: /y 7 Ztlen- iUF �rz,i ye-- City/State /Zip: AtiO4 T7M /17)N Mh (.2I(- 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 c :ft un ' - r e pairs and penalties of perjury that the information provided above is true and correct / 4/ , �'elX51 S Date: /1 I 'c — Signature: C� r , ns E�TL`�t Phone #: A / 3 - .5 S'(c' Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #:_ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: // Not Applicable ❑ Name of License Holder : (o7 , E"r �" / 9 S License Number /hril et Sr. .4/ rrfi pt ; m4 rife& c3 d.0 -17 Addr = Expiration Date A . /Am._. - cgs' '0200 , n lure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ K617-ex guL s J , Z?t'C _ 1 l0 3..qCl SS". Com pany Name r� Registration Number Address Expiration Date /00477 &le Telephone « /Y-- `k 7 – 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 ilding permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 1083.5.1. 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 ❑ Replacemen indows Alteration(s) Roofing El Or Doors ► ;! Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks ❑ Siding IQ) Other [El Brief Description of Proposed // Work: 1 X&OC 9((4VM` l v %/vim T t 2 (vizt J OYks fZ c eptit tv, rUb cO ✓ . Alteration of existing bedroom Yes Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes 1Q 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 wetlands? Yes _ No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, ,, —,7Z7Z ; / ) /1- < • g C "''T / TC , 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. S c A% 'T Print Name, / Sign. sr; of fi 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 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 O DON'T KNOW O YES O 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 O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O IF YES, describe size, type and location: E. WiII 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? YEE O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability DEC - 5 2012 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT. MP;7MA0106o p NORTHAMPTON, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: /%f t/ vcn ,6 be/ vc A,ort 7-7440, l vA , ,A64- Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: A J oS f1N be MiviZi A 14 7 ,2( vm5 r b11 Name (Print) Current Mailing Address: SeY° os�to pce-As sEf S /E/ czvp71_46T" Telephone Signature 2.2 � A / uthorized Agent: f' :7 it .6 L Deg S , . -/U C Sl R 1413 — Ci c: c..3 Sr% kbr[ rl-f11 cI /V N Name (P t) , / Current Mailing Address: 473 Si ature Telephone CTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /0/ 7S-3 (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) .P /& 7sS - YSr' Check Number 020 ..� This Section For Official Use Only / Date Building Permit Number: Issued: Signature: Building Commissioner /inspector of Buildings Date File # BP- 2013 -0625 APPLICANT /CONTACT PERSON SCOTT KEITER ADDRESS/PHONE 51A HATFIELD ST NORTHAMPTON (413) 320 -9035 PROPERTY LOCATION 147 RIVERSIDE DR MAP 30B PARCEL 058 001 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 Fee Paid `7 J Typeof Construction: INSTALL 13 REPLACEMENT WINDOWS & CONSTRUCT 1 WINDOW 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 FOL OWING 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 molition Delay ,,/"Z / 7 / S' 3 • : - of Bui ding 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. 147 RIVERSIDE DR BP- 2013 -0625 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B - 058 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- 2013 -0625 Project # JS- 2013- 001013 Est. Cost: $10754.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 24742.08 Owner: DEMARIA SUSAN Zoning: URB(100)/ Applicant: SCOTT KEITER AT: 147 RIVERSIDE DR Applicant Address: Phone: Insurance: 51A HATFIELD ST (413) 320 -9035 WC NORTHAMPTONMA01060 ISSUED ON:12/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 13 REPLACEMENT WINDOWS & CONSTRUCT 1 WINDOW POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 12/7/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner