24C-184 (3) KEITER
BUILDERSCN
2ND FLOOR BATHROOM REMODEL
SCOPE OF WORK
JANUARY 21, 2013
CUSTOMER NAME: Ronald Malmquist
ADDRESS: 200 Crescent Street,Northampton, MA 01060
ESTIMATED START DATE: Fall 2013
This contract includes the following:
■ Permit application, fees, and inspections
■ Daily site cleanup
■ Furnish and install the following items to all manufacturer specifications:
• Demolish existing subfloor
• Review integrity of structural framing
• Install rock wool insulation in floor cavity and walls for soundproofing
• Install 3/4"Advantech floor system
• Install new stud walls
• All drywall and finish
• Plumbing and Electrical
• Install new vanity
o Wall and floor the
• Re-use existing tub
• Install new built-in cabinet/shelving
o All finish trim
TOTAL PRICE FOR LABOR AND MATERIAL: $10,000.00
CITY OF NORTHAMPTON
Constr ctio Debris" Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting'fi-om any work
_ -covered:by-a-Building-PermiL shalt be d-isposed-of.in a properly licensed disposal facility,
as defined by M.G.L c..11 T § 150A.
Address of Work: o �• Q`�
fie-debris--will.be-transported by 4r�_Zza r .5. im G .
The debds.will be received.at:..
--- _ - - Signature of Permit Applicant
r
•--�--- •'- - -- . � --- - - 'Bate ..-
Bi:jildiiig Permit Number:
• T
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
„3 Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:Cq/ Tf �
City/State/Zi . 0 A� TAI MA- 016 (PO Phone #: �J 'Jig l0 0'd
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with_ �p
4. I am a general contractor and I
1.[� ❑ 6. E]New construction
/ employees(full and/or p 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 employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ,/
Insurance Company Name: �V��
Policy# or Self ins. Lic.#: .����2����70 Z�3 Expiration Date:
Job Site Addresr-.,94d rre_�;e Vd CIty"ta 1p� NA—
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 ce ify_un r e ams and penalties of perjury that the information provided above is true and correct.
Si ature: Date:
2 �
Phone#: �✓'�� )
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 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:- S c O T 7- �j/T C:5 /o 2 45
License Number
/Uo r AtiwI M A-01 o e o (0 -2 0 - za
Add ss Expiration Date
0
Telephone
9.Renistered Home Improvement Contractor Not Applicable ❑
.er ui -c rs 1751 !o 9
domoany Name Registration Number
l it -�� 41 -2°1 . 20/s
No;s ,, Expiration Date�i"m h 4 MA-®to&9� TeleOholneo to -5,G66
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 building 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 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) 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [lam] Decks [Q Siding[O] Other[1--3]
Brief Description of Proposed
Work: bAM rd x-r r--e m ad tf
Alteration of existing bedroom Yes /*' No Adding new bedroom Yes J° No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If Now house and or existina housincii, comolete the followina
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
I as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, V by Pl t y rp, f�-'G1 Y-�V- 'd VI U`GVt> I "`G 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.
a or r- K c
Prin Nam /
090ature of Own /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
Frontag-e
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 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use onty.
City of Northampton Status of Permit:
/r Building Department curb OlDnyewy Permit
�
✓�Qh► 1 / �� 212 Main Street SevverlSptic Availability
y
Room 100 Watar/Well Auatlakrilit
�:% Northampton, MA 01060 Two Sets of Striotural Rlis"
4on 413-587-1240 Fax 413-587-1272 Plot/Site'Piaits
`t/ons Other'Sp cify
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
200 /Ve!56-X'--'E- 5q, Map Lot Unit
,
/mod 1'�*,tf,4e-kr� MA- U io tP D Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
/� V- P.5u r l d e✓�, Yy+C . 51 A 31. 15Y4 A.ntt i0�XK P1 A- lo&,o
Name(Print) Current Mailing Address:
�A4 ` _ ql3-
Sign re Telephone
,SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building i C e c 7 (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
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0800
APPLICANT/CONTACT PERSON SCOTT KEITER
ADDRESS/PHONE 51A HATFIELD ST NORTHAMPTON (413)320-9035
PROPERTY LOCATION 200 CRESCENT ST
MAP 24C PARCEL 184 001 ZONE URB(54)/URA(46)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction:_REMODEL 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D it
Si a f Build' g Off is 1 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.
200 CRESCENT ST BP-2014-0800
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 184 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-2014-0800
Project# JS-2014-000391
Est. Cost: $10000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin SCOTT KEITER 102457
Lot Size(sq. ft.): 12806.64 Owner: MALMQUIST RONALD
Zoning.URB(54)/URA(46)/ Applicant: SCOTT KEITER
AT. 200 CRESCENT ST
Applicant Address: Phone: Insurance:
5 1 A HATFIELD ST _ (413) 320-9035 WC
NORTHAMPTON MAO 1060 ISSUED ON:112112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL 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 1/21/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner