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11A-026 (2) AC"RV CERTIFICATE OF LIABILITY INSURANCE 6/1(MM/DD/YYYY) /6/16/2014 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 Cynthia Henderson, CISR Webber & Grinnell PHONE 413 586-0111 FAX ( ) .(413)586-6481 8 North King Street E A -MIL .chenderson @webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC I Northampton MA 01060 INSURERA:Travelers Casualty of America INSURED INSURERS Citation 40274 Keiter Builders, Inc. INSURERC:Travelers Indemn. CO. CT 25682 Attn: Scott Keiter INSURER D: 51A Hatfield Street INSURER E: Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Exp 12/14 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP T POLICY NUMBER M D/YYYY M YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R=r D PR MI enc $ 300,000 A CLAIMS-MADE a OCCUR 6806319N6611442 6/1/2014 6/1/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC I $ AUTOMOBILE LIABILITY (Ea O aBINdEeD SINGLE LIMIT 1,0 0 000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BCDR07 12/21/201312/21/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS P r accident) $ Medical payments $ 5 000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ C WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) IEUB2A56578214 6/11/2014 6/11/2015 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C Henderson, CISR/CIN ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INGn,>rir,)ninn5int TI,.Af'C)Dn nemn­1 Innn merle of At'nDr1 sustaine.d by Contractor including,Contractor's Prof i't mid Overhead at the rate of 25-% on the balance of the illoornplet,c work under the Agreement. Thereafter, Contractor is.reliONT(l frosts all other conti�:tual duties,. including nl all Punch li List and w-arra ntv,evork. RIG 14T TO TERMENATE CONTRACT If the VNiork is stopped or delayed,either in whale or substantial part, for a period of thirN.(30)days under art order of arty court or other public authority having jurisdic::tion, or as rj. re-wit of an act of government and due to your fault or negligence,or as a resstIt of an ar:t.xvvithia ONvner's control; or if the work. delayed shall be stopped or delay either in whole or substantial parts for a period of thirty (30)days due to Owner's faihire to shake a payment on time, or make Contractor fee;t iatsecure, or if Owner should commit a material,breach:of any of Owner's responsibilities or obligations under this. Agreement,then Contractor tnay,upon.giving Owner seven(7)days written nodee,terminate this Agreement and recov-er from Owner payment for all work perform;d;for any unpaid casts of and fees for the work;.for any liability,obligations, dar13r1 C':S,cGtn"mitt#.ients.and/or claims th.-A Contractor may bave incurred or might lnctir to mood f�{tli lit contiections,i,tlli this A refinent, is well as rs eiNting payment for Contractor's attyrney's and legal. fees and all lost anticipated gross profits On the Nvork not pi:rfurmed.as of the state of the termination. NOTICE ;*donee kYill be deemed if delivered in!rand or if seat by cesrtilked trail,return rece=ipt requested.to the address listed on the frond p=,Ye of this Agreen-tent. A n!-T RA.TIO THE CONT ACTOR .-1a D THE HOMEOWNER HEREBY NfUTUALLY AGREE IN ADVANCE 'THAI' IN THE :EVENT THE, CONTRACTOR HAS A, DISUPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR NIAY *S'I,=BMIT SUCH DISPUTE TO A PRIVATE ARBITRATION .SERVICE WHICH.HAS BEEN:ApPROVIFD BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUIMER AFFAIRS AND BUSINESS REGULATIONS AND THE COitiSlil►I)?}2 SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS.GENERAL LAWS,C:142A. kEITER BUILDERS,INC.(CONTRACTOR) OWNER I�:, cofit=.'.Cher,President mate w � max* Date --- NOTICE . THE SIGNATURES OF THE, PARTIES A;BOVE APl LY ONLY TO TITE AGREEMENT OF T14E PAR`I'IF "I�3 ALTERNATIVE DISI?.UTE SETTLENIE'*}T INT:TTATED BY TI-IF I CONTRACTOR. THE O\VNEA MAY INITIATE ALTEIkNATIVE DISPUTE RESOLUTION :EVEN WHERE TI-ITS SECTION 1S NOT SEPARATELY SIGNETS BY T HE P RTIES. WE RIGHT TO INIT"IATF ALTERNATIVE DISPUTE RESOT.UTION SHALL E.NI.} TWO YEARS AFTER THE DATE OF'i•IIIS AGREEE MENT.. l oUlner co --: `___._.. . .CI`1 Y OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work —__-_---__._ reruered by-a Btri}ding Permit-shalt be disposed-of.in a�properly licensed disposal facility, as defined by M.G.L: c. 111- § 150A. Address of Work: U 1p C c� c)lOS 3 �lae-d�bris_Ml.be-transported by: The debds.wiil be.recewed at:. ff,^ I I Sfgnature of P TA`pG l5 cant T r t 6wA td11V3 1-t C. Date Building Permit Number: • i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual):_ e t e r 6-Z 1clacs I h Address 9S ^ 5�- City/State/Zip: laoffA�`,C, M A 0106 Phone#: 7/;�j ��� �t!iCID Are you an employer? Check the appropriate box: Type of project(required): 1. l' I am an employer with--1— 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 7. ❑ Remodeling listed on the attached sheet. 2. ❑ 1 am a sole proprietor or partner- These sub-contractors have 8. 9 Demolition ship and have no employees employees and have workers' working for me in any capacity. comp. insurance.$ 9. ❑ Building addition [No workers' comp. insurance 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its officers have exercised their 11.❑ Plumbing repairs or additions 3. ❑ I am a homeownerSeattle8 doing right of exemption per MGL c. 12.❑ Roof repairs all work myself. [No workers' 152, 51(4),and we have no comp. insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also 511 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. lContractors 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 dnsurance for my employees.Below is the policy and job site information. Insurance Company Name:- —V C-c V 12LU r'.S \nsu-(Ol✓ ce, Policy#or Self-ins.Lic.#: ,EQ-&M S.65' L{ Expiration Date:�!/ / Job Site Address: All Locations ), C kP lay\cQ. (XL City/State/Zip: L-e-9 _S, VVl Y� v tOS3 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:��'(.t / Ae-M" k.u�y 6,4-6 l-C Date: ­4 a-\ `1 L Phone#: V!3 $( Gp 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#: Z:\Workers Comp Aff-Highlited.doc SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor, �p Not Applicable ❑ Name of License Holder: oy' tt( �"' / plS—I License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Le(" ter 6c< l nl,- I-J !Q 6 g Company Name �l Registration Number � Address ++,, 22 Expiration Date 7 Telephone /7 ,5 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 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) :1 New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ �j Or Doors F-1 Accessory Bldg. ❑ Demolition CJ New Signs [O] Decks Siding[E:3] Other[O] Brief Description of Propposed Work: 1'y1-tc1,Dr Dl'sw1 a Alteration of existing bedroom Yes--Y— _No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 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 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 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. CZ Print Namer Signature of Owner/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/Findi ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:!' IF YES: Was the permit recorded at the Re ' try 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 0 YES 0 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 0 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use onty City of Northampton Status OUP uilding Department Curb.CuttDrive�+ y Perm 212 Main Street Sewer/SeIptip Avallabtiity V •� 2 20� Room 100 Water/Well'Auailability 4 rthampton, MA 01060 Two Sets of Structural Plans Electric, PiumLing Gas n 41 -587-1240 Fax 413-587-1272 Plot/Site Plans North-:prlcn. ? inspections ZitherSped I �'A 01066 fX "`.. 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 a� q,...J. 9--k Map Lot Unit Zone Overlay District 0105 Elm St.District CB District SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: &/A-AJ �j Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: 't-eA-e.'r YYl�oto� a- Name(Print) Current Mailing Address: ?600 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 'P7 CX)o c° (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) �S c . 0 Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0088 APPLICANT/CONTACT PERSON SCOTT KEITER ADDRESS/PHONE 51A HATFIELD ST NORTHAMPTON (413)320-9035 PROPERTY LOCATION 23 UPLAND RD MAP I IA PARCEL 026 001 ZONE URA000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: INTERIOR DEMOLITION New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 102457 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: -"'-Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management n Delay Signature of IKilcTing 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. 23 UPLAND RD BP-2015-0088 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 1 IA-026 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INTERIOR DEMOLITION BUILDING PERMIT Permit# BP-2015-0088 Project# JS-2015-000151 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sc. ft.): 18861.48 Owner: CHEEVERS NANCY Zoning:URA(100) Applicant: SCOTT KEITER AT. 23 UPLAND RD Applicant Address: Phone: Insurance: 5 1 A HATFIELD ST (413) 320-9035 WC NORTHAMPTON MA01 060 ISSUED ON.712412014 0:00:00 TO PERFORM THE FOLLOWING WORK.INTERIOR DEMOLITION 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 Sisnature: FeeType: Date Paid: Amount: Building 7/24/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner