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07-061 CERTIFICATE OF LIABILITY INSURANCE 1 u "'Ct'"rv'+uu'r r'r' 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 INSURERIS). AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED. the policyties) 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. Lac °NroerL 413.586.0111 L �ac 413 586.6481 8 North King Street EMAIL ADDRESS: Northampton, MA 01060 PRODUCER 00021099 CUSTOMER 1D 4. INSURER(S) AFFORDING COVERAGE 1 NAIC # INSURED - - - - - - wSURERA: Travelers Casualty of America rt Keiter Builders, Inc. INSURERS: T ravelers Indemn. Co. CT 5682 51A Hatfield Street 12 N SURER C — --- __ -_ -- — ._ - - -_. IN Northampton, MA 01060 INSURER D: INSURER E : 1 t INSURER F 1 COVERAGES CERTIFICATE NUMBER: Master Exp 06/13 REVISION NUMBER: I 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 - - -_ -- - -- -__ -- ADDLSUBR - - -- POLICY EFF POLICYEXP — LTR TYPE OF INSURANCE INSR ; WVD • POLICY NUMBER LIMITS {MMIDDM'Y1� {MMIDD/YYVY) GENERAL LIABILITY I680631 06101/2012' 06101!2013 ... I 1,000,000 X _.Li (t 300,000 X Fr ii 5,000 A H , , r it 1,000,000 i , 2,000,000 �r. 2,000,000 AUTOMOBILE LIABILITY --- .� - "-� : • = - - l I . — i t • UMBRELLA LIAR e - _ I „ EXCESS LIAR - _ - - - _ M t I , WORKERS COMPENSATION IEUB2A56578212 06/11/2012 06/11/2013 , .' r A EMPLOYERS LIABILITY Y 1 N , B PIFT, 4 . t " NIA F l r,■r t 100,000 V_ r_ - - _ - -- I (Mandatory in NH) • F E .t ■ - I n `F-1 I 100,000 i -BFI :- I,::: , ,, - t ;,,_ L.14 j 500,000 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 d ,, .. For Information Only :.= Cynthia Henderson, CISR /CINDY lWA4�! i © 1988-2009 ACORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents ,r „ Office of Investigations .4 1 Congress Street, Suite 100 - 4, ,` Boston, MA 02114 -2017 " ,.' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information J/ Please Print Legibly Name ( Business /Organization/Individual): IC 621. r c =NC . Address: 5(A 14Arre 1C LD S , City /State /Zip: \tY►tivi - g ∎, rtd/1 6I040 to Phone #: ( 7 7 • SP6 . f54,0 O Are you an employer? Check the appropriate box: Type of project (required): 1. I,►: a m a employer with _ 4 . ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working employees and have workers' g for me in any capacity. 9. ❑ Building addition INo 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.E1 Roof repairs insurance required.] t c. 152, §1(4). and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box ##1 must also 011 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. ' 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: in. ikvet—e-FtS Policy # or Self -ins. Lic. #: rE u (a 2 ttS(2S - 7152.1 Z Expiration Date: Co • 11 • 2- 0 1 3 Job Site Address: 3 (07 IV on-T14 - A4 N.S i s," City /State /Zip11104.17- 4 , A44. 01 o (0 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 imprisomnent, 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 • y L under th paand peenalties oof 7 perjury that the information provided above is true and correct Signature: t /� �C f't� ,'t�l 4.,0t3'LS C ate: / 3 1 3 Phone #: / 3 - ST/ Gv - 4e: 0 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 #: .ADITIONAL MATERIALS The following items are not included in this contract: • Toilet • Vanity • Sink • Faucet Set • Towel Racks • Toilet Paper Holder • Shower Fixtures, Mixing Valves, Trim • Tub • Light Fixtures • Glass Shower Door • Mirror / Medicine Cabinet SUBCONTRACTORS Note: Keiter Builders marks -up all subcontractor work by 15 %. Prices below reflect this mark -up. ELECTRICAL $546.25 o Please see attached document. ($475.00 + Mark -Up) o This price includes a bathroom exhaust fan PLUMBING $3,371.51 o Please see attached document. ($2,931.75 + Mark - Up) TILE $2,233.92 o Please see attached document. ($1,942.54 + Mark -Up) TOTAL PRICE: $11,026.69 o f '. `i t x., ". vt BUILDERS � SCOPE OF WORK December 23, 2012 CUSTOMER NAME: Marilyn Woodman & Raphael Hartzog ADDRESS: 367 North Farms Road Northampton, MA 01062 ESTIMATED START DATE: Winter, 2013 ESTIMATED PROJECT RUN TIME: 3— 4 Weeks ADMINISTRATION • Keiter Builders, Inc. will manage the following aspects of the project: o Building permit application (Please note that this contract does not include a building permit fee) o Standing all necessary inspections o Subcontractor oversight and management ` / o Materials ordering and delivery 1\11 l( o Site set -up and break -down o Certificate of Occupancy BATHROOM RENOVATION SCOPE OF WORK: Renovate existing bathroom. No change in room dimensions. Remove and dispose of existing vanity, sink, toilet, shower, tub, all plumbing fixtures, mirror, and miscellaneous fixtures. This contract assumes that all plumbing and electrical fixture locations will remain the same. This contract includes all demolition and debris removal, carpentry, paint, skim coating, bathroom fan venting, and subcontractor management. LABOR • $4,000.00 o Cost for Keiter Builders lead carpenter. All carpentry and project management MISC. MATERIALS $500.00 o Cost for miscellaneous carpentry materials and equipment o Cost for debris disposal ADDDITIONAL TO ORIGINAL PROPOSAL $375.00 o Bathroom fan venting ($125.00) o Skim Coating and Primer ($250.00) 4 tl " REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A. 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 B E FO R E SIGNING. KEIT ,R BUILDERS, INC. HOMEOWNER /'i(7L7 a'23' ��- ^ f , Scott Keiter, its president Date to / • ate 5 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : S „ j16-- -resit_ /0,2( < License Number 61 4 # m- s i• keizTrr i7� ✓vj M ,A 01O6 v 6, • o- an 5 Addres 0 Expiration Date fry cg, -O, °o S' ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 1 4 - aril eo k c — vt,S ..— C. 1 � , 3 a g S Company Name Registration Number 57,4 417-f7 ST . /tla4rrAa„ zv, AAA 6.) ( /a L • 1 - a. o r 3 Address VV Expiration Date Telephone 993' 3F ' oC) 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 bui ding 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 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- e6nsidered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to t ' ding 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 , e 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 (W • ers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of • assachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this • • .t. The undersigned "homeowner" certifie s d assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State . I : ,ocal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signa . e SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [ED Siding [1:1] Other Brief Description of Proposed Work: Work: BAT - 2 OOM RE N 0' 91 c.p Alteration of existing bedroom Yes -No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes D` No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of 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. 1 ) 1..e#€ SEE aT11NC14 . ) S16nIE rntialAC1 Signature of Owner Date 1, o - R - K.W__ , 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. c - -7e-1— Print me / • .2 3 • / 1 ature f Owner /A ent Date 1 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 o10 Open Space Footage F lo (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 DON'T 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. Will the construction activity disturb (clearing, grading, excavation, or fillings over 1 acre or is it part of a common plan that will disturb over 1 acre? YE: 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 Bu Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability JAN 2 5 2013 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT. L'(7 U '. :.: ne 13-587-1240 Fax 413- 587 -1272 Plot/Site Plans NR7HA�ap70N. tit 07060 f Other Specify 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 3(7 S n �� Map Lot Unit FL..o n en) cG ,u , � � t o o b t_ Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Attie 21 L' J Loop I A nl 3 ( 7 N- 21:>. "C G—nic f r c o t Name (Print) Current Mailing Address: '7y ' s • 7S2.3 Telephone Signature 2.2 Authorized Agent: 1471 - rr-►t Q v c -17ctiS 9A y?7 fi Eci) ►"-t Nan a (Print) �j Current Mailing Address: l)1s. 'I/3 • S 0 ignature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7 f 08 9 3 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 6 - z Construction from (6) 3. Plumbing 3-3 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection J �j /� 6. Total = (1 + 2 + 3 + 4 + 5) // o 2 G , 49 Check Number d 41112(0 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0720 APPLICANT /CONTACT PERSON SCOTT KEITER ADDRESS/PHONE 51A HATFIELD ST NORTHAMPTON (413) 320 -9035 PROPERTY LOCATION 367 NORTH FARMS RD MAP 07 PARCEL 061 001 ZONE RR(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Ar-P- #/ _ Fee Paid (l/(O Typeof Construction: RENOVATE BATHROOM 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: roved 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 Dela `/ /j575 Signature of Building • fficial 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. 367 NORTH FARMS RD BP- 2013 -0720 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 07 - 061 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 -0720 Project # JS- 2013- 001215 Est. Cost: $11027.00 Fee: $66.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 24567.84 Owner: WOODMAN MARILYN J Zoning: RR(100)/WSP(100)/ Applicant: SCOTT KEITER AT: 367 NORTH FARMS RD Applicant Address: Phone: Insurance: 51A HATFIELD ST (413) 320 -9035 WC NORTHAMPTONMAO1060 ISSUED ON:1/28/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 1/28/2013 0:00:00 $66.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner