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11A-026 (3) V CITY OF NORTHAMPTON PT ON �. Construction Debris Aff-idaVit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work rover-ed:by-a-B-uildipg Perrot-shalt be disposed-of.in a--properly licensed.disposal facility, as defined by M.G.L: c.•111• § 150A. Address of Work: CGC.��. v(d 3 �lae.-ci�bris_MI.be-transported by: The debds.will be.received - — — - Signature of Permit- 'plicant 'Date Building Permit Number: ' T SUBCONTRACTORS(COMPLETELY INSURED) • STEVE WILSON, ELECTRICIAN • Jt�HN THOMAS*PLUMBING& HEATING r TODD ALEXANDER,SITE WORK • svr. FLOOR COVERING, FLOORING AND WAIJ. TILE • RIGHT WAY DRYWALL ■ J4 RRY BANISTER PAINTING 'IIMS CONICRLTE • CAMPBELL IRON WORKS ■ WIL.DERS INSTALLED PRODUCTS,INSULATION EXCLUSIONS • FINAL,DEEP CLEANING • PAINT AND FINI`UI • HOME:FURNISHINGS • APPLIANCES • INSTALLATJON OF HOT, TUB • TDILET.PAPER HOLDERS,MIRRORS,MEDICINE CABINETS.TOWEL RACKS • GARBAGE DISPOSAL fir✓ Initial Nere. Aw � r FtE_AT�I�(� • 114LOCATE DUCTWORK PER PLANS VE1VT'[I�A�1_UN • DUCTWORK FOR NEW RANGE HOOD VENTILATION SYSTEM • DUCTWORK FOR IST FLOOR BATH.VENTILA"ITON SYSTEM • DQCTVl%'ORK FOR(I)ELECTRIC DRYER 26-ELECTRICAL • CELIF MICA L FJXnfRE ALLOWANCE: $1,000.00 • MISC.DEMOLITION AS NECESSARY • RE-ROUTE AND REUSE EXISTING KITCHEN,BATH,&I.AUINDRY CIRCUITS • DEDICATED CIRCUITS FOR.F:RIDGE,MICROWAVE,, DISHWASFfk?K • PROVIDE AND INSTALL.RECESSED LIGHTING AS INDICATED ON DRAWING • INSTALL SWITCHING AND RECPTACLE OUTLETS AS RFQIJIRI D • WIRING FOP,PROPOSED HOT TUB • SERV:ICfE UP'GRAADE'170 200A 240/120V SINGLE-PHASE(EXISTING 100A SERVICE INADEQUATE 1-0 SUPPLY EXISTING LOAD PLUS PROPOSED HOT TUB) 31 —EARTHWORK • FOUNDATION EXCAVATION AND BACKFI LING c CUT AND REMOVE EXISTING DRAIN LINE,AS:REQU[R.E D o ANY ADDITIONAL PILL WILL BE REMOVED FROM SITE o FURNISH AND INSTALL,(1)PRE-CAST CONCRFTF PIER FOR ADDITION • PRE-CAST PIE-RS FOR DECKS AND PORCHES o SUPPLY AND tNSTALL 6 PRE-CAST CONCRETE PIERS FOR THE DECK. o FINAL GRADI.NGILOAM AND SEED • FINISH GRADE SITE TO PROVIDE POSITIVE DRAINAGE AWAY FROM THE FOU rNDATION • INSTALL PEA,STONE AN.D FILTER FABRIC BENEATH NEW DECK AND ADDITION, AREA • SPREAD 4-6"OF SCREENED LOAM ON THE LAWN AREAS • HYDRO-SEED THE LAWN AREAS WINDOWS&:DOORS WINDOW.&DOOR ALLOWANCE: S8,300.00 • ALLOWANCE INCLUDES ALL.HARDWARE r All MISC. MATERIALS INCLUDING DI?JPCAPS,PAN FLASHING,FASTNERS,ETC. • LABOR AND INCSC, MATERIALS TO INSTALL;DOORS AND HARDWARE • DRYWALL. '/a" DRYWAIA,INSTALLED AND FINISHED. PAINT READY • INSTALL FLOORING AS SHOWN IN PLANS c 3 ',"t"RED OAK WITH(3)COAT POLYU:RET14ANE SYSTEM IN KITCHEN.&DINING AREA o CERAMIC TILE(SG.00ISF ALLOWANCE FOR TILE)IN BATH/LAUNDRY AREA • EXTERIOR PAINTING. o OWNER TO PAINT AND FINISH • INTERIOR FAINTING. o OWNER TO PAINT AND F:[N.ISH • BACKSPLA.SH TIDE MATERIAL&,t,ABOR ALt.OWANCt's: $1,450.00 • BUILDING WRAP,SIDING,EXTERIOR TRIM-MATCH EXISTING • MISC.EQUIPMENT-STAGING,LADDERS,DELIVER,PIU,CONSTRUCT,ETC. 12-FtiRNI5HTNGS�--� .......-.--.-._..____,._....-. _.._.__.__..__......_.._._._....�.....^..^._._ • OWNER SUPPLIED 22- I'LLtMBl!NG S I-IEAT(NG..Y._._._. • PLUMBING FLX'I'(JRE ALLOWANCE: $21500.00 o FIXTURES INCLUDE:. SINKS,SHOWER,"TOILET,I'AUCET,VANITY&TOP,FAUCETS,SOAP DISPENSERS,SHOWER VALVES,SHOWER FIXTURES,SHOWER DOOR PLUM_BI�vFf • DEMOLITION AS REQUIRED • PLUMBING FOR KJTCfI.EN SINK,DISHWASHER,ICE MAKER,NEW I Sz FLOOR.BATH.&LAUNDRY,(]) NEW-OUTSIDE FAUCET @ FRONT RIGHT CORNER OF HOME ■ RELOCATE SLOP SKINK WASTE LINE IN BASEMENT TO ACCOMMODA°I-E NEW POST GAS Hers • RELOCATE GAS LINE FOR NEW RANGE LOCATION • misc.. BATH f LAiJN.DRY FINISH. (SET VANITY,MISC.TItI.M,TOWEI,RACKS,'IP HC?L1�ER 1�Ilfi�tOR, • FINISH(2)CLOSETS. STANDARD= (1)POLE,(1)SHELF KII:.�HEN. ■ ALLOWANCE: X9,975 FOR CABINETS -STANDARD CONST. 54,200.00 FOR.G..ANITE COUNTERS • MEDALLION"SILVERLINE SERIES"CABINETS WITH STANDARD CONSTRUCTION • CARLISLE VENEERED RECESSED PANEL DOOR STYLE WITH A SLAB DRAWER HEAD IN MAPLE • CLASSIC WHITE CHOCOLATE;PAINTED FINISH WITH MOCHA HIGHL[GAff • FUEL EXTENSION/SOFT CLOSE DRAWER GLIDES&SOFT CLOSE HINGES • CUSTOMER CHOICE OF PULLS&KNOBS(PART OF ALLOWANCE) • CUSTOM GRANITE COUNTERTOPS WITH POLIS'HI D CUTOUT FOR UNDERJ+I;OLIN1'EI)SINK • STANDARD EDGE TREATMENT(PENCIL OR:BEVE=L) • TEMPLATE,DELIVERY,INSTALLATION OF COUNTERTOPS • BACKSPLASH(SEE.09-FINISH) NOTE: CLIENT IX3F,S NOI'WANT GRANITE BACKSPLASH • ALL.CARPENTRY AND MISC.MA'T'ERIALS INSTALL CABINETS AND FINISH KITCHEN BATI�ROOM .;LA;UN3RY • CADINE"tS&.COUNI'ERTOP FOR.BATI I f LAUNDRY(AI,I,OWANCE): S900.00 • ALL CARPENTRY TO INSTALL CABINETS,COUNTERTOPS,MISC,TRIM,TOWEL.RACKS,T.P.HOLDER, MIRROR,ETC:. 07-THERMAL.&MOISTURE • ALI.CAULKING&SEALANTS tI 1It� • INSULATION. o R-50 LOOSE FILL,CELLULOSE IN CEILING OVER N EW AREA o R-21 DENSE PAK CELLULOSE IN AFFECTED WALLS o LOW EXPANSION SPRAY FOAM INSULATION AROUND ALL FENESTRATIONS o A.CCUVENT AT RAFTER BAYS TO.PREV.ENT WI.NDWASHING o POLY-ISO FOAM INSULATION AND AIR SEALING BENEATH ADDITION • ALI.MISC.Alta INFI IRATION.PREVENTION AND AIR,SEALING • INSTALL A :FA.BRAI,GRANT RIB PLUS(COLOR)PANEL SYSTEII4 AT ENTIRI>DOWER BACK'RCQOF • STANDARD,WHITE GUTTERS AND DOWNSPOUTS AT ENTIRE BACK ROOF LOCATION • (6)PRE-CAST CONCRETE PIERS TO SUPPORT NEW DECK (23 30X30X12 PADS FOR COLUMNS. CUT,DEMOLITION,EXCAVATE, REBAR,POUR CONCRETE • (2)CONCRETES FILLED,STEEL LALI,Y COLUNNS NV/SPRINGFIELD PLATES 04—MASONRY NOT APPLICABLE 115-ME'I<'AI;S • ALL.WALL,ROOF,&.MISC.FLASHINGS • STEEL PORTAL FRAME 4"SQUARE STEEL.COLUMNS WELDED TO 12"!SEEP STEEL W-S> CTION (IE3F:AM)TO RESIST WIND LOADING AND TAKE ROOF LOADS. BOI.;F TO TIMBER.SILL,STRAP TO FOUNDATION • ALL STEEL IS SHOP PRIMED • STRUCTURAL&EPDXY BOLTS ■ FIELD VISIT/MEASUREMENTS,SHOE'FABRICATION,STEEL LOADING;, HURRICANE STRAPS,HOLT tO WALL AND WELD TO COLU MN 06-WC}C3t?$z PLASTICS • ALL STRUCTURAL,WORK AND FRAMING AS SHOWN IN PLANS • SU:R LOOR.ING!LEVEL ROOMS;FLOOR PREP.- PENDING FURTHER REVIEW WITH CLIENT • FRAMING FOR NEW DECK.AS SHOWN IN PLANS, JOISTS 1.2"O.C. DUFS NOT INCLUDE STAIRS TO GRADE. • MISC, FIRE BLOCKING,BLOCKING FOR DRYWALL,ETC. FE�s SN�.AR_PI~1�ICRY. • DECK: o CAMSARA:PLANKS WISTAINLESS STEEL FASTENERS o 1 X 10 PVC FASCIA o CEDAR RAILING ASSEMBLY • DOOR CASING, WINDOW CASING,EXTENSION.IAMBS STOOLS,APRONS, BASE 130ARD(INTERIOR) • CROWN MOLDING�-NA • lvfISC.MOLDINGS KEITER I L D C $C.0-PE OF W+QR JULY 16,X114 CL'SMOMER NAME: NANCY CfIFEVERS&KATH HAYFOR.D . Em_ 23 UPLAND ROAD,LEEDS,MA ESTU"TIED START DATE: AUGUST 1,2014 ES'IPAATED PROJECT RUN Timr-,: 8-10 WEEKS PLANS&SPECIFICATIONS: MARK GELOTTE. BUDGET PLANS DATED 46.23.14 ADDITION AND REMODEL ALL PRICES ARE TO FURNISH & INSTALL,UNLESS OTHER'W'ISE NOTED � !: w. 01. GENERAL CoNniTIUiVS�^ ___—_ -------------__. ------------------------ , " • CONSTRUCTION i PROJECT MANAGEMENT • PERMIT,APPLICATION,FEE3S,AND INSPECTIONS = DUMPSTER,DEMOLITION,AND DEBRIS REMOVAL • PORTABLE JOB TOILET • SITE SET-UP AND BREAKDOWN • :MATERIALS ORDERING,DELIVERY,AND HANDLING • WEATHER PROTECTION • BLLtEPR1NTS AND REPRODUCTIONS • RENTAL.EQUIPMENT AS NECESSARY • PROJECT ISOLATIO I AND DUST CONTROL • TEMPORARY SHORING • ALL DEMOLITION i#ia[Here • INSTALLATION OF NEW,OWNER-SUPPI,IED APPLIANCES x i U, ` p R Keiter OuI(ders Inc 35 Main Street Fto rencr MA•01062 Phone 413 586-8600-Fax 413 28MI2a kefterbui demcom { LS t PAYMENT SCHEDULE (Total Due = $159,525.00) i > i i 'PA>'M>G*T -SC121PTION DUE _ AMOUNT 7 i 1 1i3 of r 'ect cost _ `Pith Si ned Contract SS3 1.75:00_M� c 2 i13 of�iroject cost _ At rough fratnilns ciion $53,175.00 1 a 2UDlo of prt�jcct cost lApproximatelyMCOmpletion i$311905.00 final Payment Substantial Completion !S21,270.00 { i } I 1 x i 1 i i t 1 4 ! t �Y snuinW by Contractor: including Contractor's Prolit and Overhead at the rate of;5_1116 on the balance of the incomplete ar k under the Agreement. Thereafter, Contractor is relieved from all other contractual duties, including all Punch List and>karranty work. 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 corm 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 Owner's control; or if the work shall be stopped or delayed either in whole or substantial }rant, for a period of thirty (30)days due to Owner's failure to make a payment on time, or make Contractor feel insecure, or if Ocaner should commit a material breach of any of Owner's responsibilities or obligations under this. Agreement,then Contractor may,upon giving Owner seven(7)days written notice,terminate this Agreement arid.recover from Owner payment for all work.performed; for any unpaid costs of and fees for the work; for any liability,obligations, damages.commitments,andror claims that Contractor may have incurred or might incur in good faith in connections,with this Agreement, as well as receiving payment for Contractor's attorney's and legal. fees and all last 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. ARBITRATION THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAI` IN THE EVENT THE CONTRACTOR HAS A DISUPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH.HAS BEEN APPROVIE.D 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 BUILDERS,INC.(CONTRACTOR) OWNER 1 Batt Keiter,President Bate tc, Date -- it NOTICE THE SIGNA,ruRES O F THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTcRNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT' SEPARATELY SIGNED BY o-HE PARTIES. TTIE RIGHT TO INITIATE. AI:TERNATIVE DISPUTE RESOLUTION SHALL. END TWO YEARS AFTER THE DATE OF THIS AGREEMENT. &, IO Conwactor . owner._._ .t ii ta. Additional Work. Contractor to supervise,coordinate,and charge 2511/6 profit and overhead on the following:all Additional Work under this Agreement, Additional Work,: caged by concealed conditio[TS, al! or'era ges an ALLOWANCE work,.all{owner-furnished materials, and all work of Owner's separate contractors who are working on site at same time as Contractor. The antount of the Additional Work will be reasonably `detertnined by the Contractor,and will be Subject to Contractor's profit and overhead as noted above. Contractor's profit and overhead, and.any supervisory labor will not.be credited back to Owner with any deductive Change Orders(work deleted from Agreement by Owner). RATES CHARGED FOR ALLOWANCE-ONLY AND TIME-AND-MATERIALS WORK Journeyman Carpenter: $5..4 per hour; Apprentice Carpenter: $I,. per hour; Laborer: $1. per hour; Contractor:$59 per hour;Subcontractor:Amount charged by Subcontractor.Mote: Contractor will charge for profit and overhead at the rate of 25%on all wort: performed.on a Time-and-Iviateriais basis(on both materials and labor rates set forth in this Agreement) and on all costs that exceed specifically stated ALLOWANCE estiinates in the Agreement. FSOME AUTHORIZED TO SIGN CHANGE ORDERS i people are authorized to sign Change Orders: " liars)above at time of signing Agreement) °r . . „ *is work, Keiter Builders, Inc., or subcontractors hired by Keiter Builders, Inc., will obtain, on Owner's permits(if required): s � Pttmit x Electrical Permit Smoke Certificate Permit �X Demolition Permit 3.._ Certificate of Occupancy AT ION OF CONTRACTOR TO OBTAIN THESE: PERMITS AS YOUR AGENT. IN THE [ RACTOR DOES NOT OBTAIN THESE PERMITS, AND THE OWNER OBTAIN 'T S ; 'RACTOR IS NOT REGISTERED WITH THE BOARD OF BUILDING: REGULATIONS, k{ BE ENTITLED TO OBTAIN ANY BENEFITS FROM THE GUARANTEE FUNIl AIASSACHL3S ;TTS GENERAL LAN'VS CHAI"TER I42A. �s to obtain permits is limited to those permits directly related to performing the work Contractor mat other permits or governmental or regulatory agency approvals,such as,but not limited to, a spec-�d permits,site plan approvals,or approvals of conservation commissions,are required to be 4 obtain their permit,, it is the Owner's obligation to satisfy such requirements and to meet er's cost. . AND PAYMENT TERMS 4 t ing the work and supplying the materials under this Agreement is E. Fives LjuAdred and Twee Ft.e(SI59,,525.00) DOI..I.AI2S. Payments against work . sr will be made within 2 days from when Contractor notifies Owner that Contractor has jj w ^ ' Owner i iz hs ' *4 u CONSTRUCTION AGREEMENT THE AGREEMENT PARTIES This contract (hereinafter referred to as "Agreement") is matte and entered into on this 1.7a" day of July, 2.014, by and bet-veer Nancy Cheevers & Kath flayford, (hereinafter referred to as "Owner"); and Keiter Builders, the., of Florence. MA whose Federal Tax Identification Number is 27-21518846; Contractor's Registration Number 175368 (Exp. i#4-29- 'O15).And License##102457 (F•.xp, 06-20-2016), (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work,sultject to the terms and conditions below: ALL RESIDENTIAL CONTRACTORS AND SUBCONTRACTORS ARE REQUIRED TO BE REGISTERED WITH T1 4E 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 ASH-BURTON PLACE.ROOM.1301,i3OS"TON,MA 02418(617)727-8598. GENERAL SCOPE OF WORK Contractor will perform the work set forth in the attached Scope of Work on Owner's home. or,the property located at 23 Upland Raacf,Leeds, 1A. if Owner would like to change any work to be performed or materials used,Contractor and Owner will have to make such changes through a Cltanhe 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. Contractor reserves the right to make minor changes in any plans and to substitute materials of equal or better duality. Should Contractor encounter any unknown conditions below the surface of the ground, or concealed or unknown editions in any existing structure, Owner will agree to make an equitable adjustment with Contractor under a Change Work Order,which shall increase the total price and extend the date for substantial completion of the work. THE CONDITIONS FACLUSIONS Tis Agreement does not inciude latx)r or materials fbr the following work: PROJECT-SPECIFIC,EXCI.UfiIONS , Sf F SCf) Q V►ToRIC___--.____.._...._. __._._:..__.__ STANDARD EXCLUSIONS Unless specifically included in the "General Scope of Work" section above, this Agreement does not include labor or materials for the following work: Plans, engineering fees, or governmental permits and fees of any kind. Additional work required by governmental plan checkers on final"Red Lined"Job copy of plans that are yet to be issued. 'Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA). Custom milling of any wood for use in project. Moving owner's property around the site. Labor or materials required to repair or replace any Owner-supplied materials. 1Zepaiir of concealed underground C}w tier._.. 7 ® DATE(MM/DD/YYYY) AC"° CERTIFICATE OF LIABILITY INSURANCE 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). CONTACT Cynthia Henderson, CISR PRODUCER M , y Webber & Grinnell PHONE (413)586-0111 FAX (413)566-6481 8 North King Street E"MAIL .chenderson @webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA:Travelers Casualty of America INSURED INSURER B:Citation 40274 Keiter Builders, Inc. INSURERC:Travelers Indemn. CO. CT 25682 Attn: Scott Keiter INSURER 0: 51A Hatfield Street INSURER E: ,Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER Xaster 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. rA ADOL SUBR POLICY EFF POLICY EXP LIMITS OF INSURANCE POLICY NUMBER YYY M YYY Y EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 GENERAL LIABILITY PR MISES oc rr nce $ MADE ❑X OCCUR 806319N6611442 6/1/2014 6/1/2015 MEDEXP(An 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 X1 POLICY I P,R& LOC $ AUTOMOBILE LIABILITY C a accideD SINGLE LIMIT 11000,000 BODILY INJURY(Per person) $ B ANY AUTO ALL OWNED X SCHEDULED CDR07 12/21/201312/21/2014 BODILY INJURY(Per accident) $ AUTOS NON OWNED a n PROPERTY DAMAGE $ X HIRED AUTOS AUTOS $ 5 000 Medical payments UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED t I RETENTION C WORKERS COMPENSATION X WC STATU- OTH- 111 AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? L!!j N/A IEUB2A56578214 6/11/2014 /11/2015 E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below 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 ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE C Henderson, CISR/CIN OF- ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSnq;i9n1nnri ni TMn n of A/`nQn 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): ec 1�C Address: -J5 (v\ S ,J / City/State/Zip: J`ekAu D t D(� a" Phone#: l/3 �SSb 0 00 Are you an employer? Check the appropriate box: Type of project(required): 1. I am an employer with 10 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 7. ennodeling listed on the attached sheet. 2. ❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition ship and have no employees employees and have workers' 9 ❑ Building addition working for me in any capacity. comp. insurance.']: [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. ❑ 1 am a homeownerSeattle8 doing right of exemption per MGL c. 12.❑ Roof repairs all work myself. [No workers' 152, §1(4), and we have no comp. insurance required.] j 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. 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. e--:— Insurance Company Name: \TCt0e- f_,, I auk / Policy#or Self-ins.Lic.#: US Z 1'1 St�S 3"Up� 1q Expiration Date: / /LLI Job Site Address'All Locations City/State/Zip: 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: Date: 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#: Z:\Workers Comp Aff-Highlited.doc SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ / Name of License Holder:.G(0 mil\ n c,, —1 O a l S License Number Address Expiration Date U Sib �6ov ature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ )r=�6 ��-c,i�c�ors . I Kf_ I 5 16 g Company Name Registration Number AIK G o�vb� ylacf 1 r Address Expiration Date Telephone 0 V �6w 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 dwellin,-,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,durin-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 resultinu 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 undersi-ned"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 WO FIK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ Ne Signs 101 Decks [ 1 Siding[01 Other[P 10"I Lum , Brief Description of Proposed Q Work: �4 170fEN f, Li V 1"(-0 Alteration of existing bedroom Yes X No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet V 6a. If New house and or addition to exisltina housing, complete the followincl: 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? N 0 d. Proposed Square footage of new construction._ (O Dimensions K I o e. Number of stories? NEW A't>'t�tTl°iU = 157an-`r f. Method of heating? lAoT Fireplaces or Woodstoves N Q Number of each g. Energy Conservation Compliance. — Masscheck Energy Compliance form attached? h. Type of construction W oo1 i. Is construction within 100 ft. of wetlands? _Yes K No. Is construction within 100 yr. floodplain es No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? X Yes No . I. Septic Tank City Sewer_1/ Private well City water Supply X SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i LEA SE SeC— 4,-r e,Crt&- S\N6� CoNP(—r-AC 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. Print N e � r(L � IN 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 18886 same Frontage 133.65 same, Setbacks Front 351511 '35'-5' Side L: 60' R: 16'-1', L:60' R: 16-9' Rear 62'-6' 48'-6' Building Height 31'-1 31'-1', Bldg.Square Footage 2005! 10.6 ' % 2373' 12.5 Open Space Footage % (Lot area minus bldg&paved 1688 89 1651 87 parking) #of Parking Spaces 3 3 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:`'1`!l IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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. Depirtment use only:, f� ity of Northampton Status of Permit: DL� uilding Department Curb Cut/Driveway Permit 02014 21.2 Main Street Sewer/Septic Availability Room 100 Water/Well Availability No hampton, MA 01060 Two Sets of Structural Plans ; Electric,Plumbing&c jjh ec s Northampton,N � - 87-1240 Fax 413-587-1272 Plot/Stte Plans Other Specify: """. APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: nn n This section to be completed by office Map Lot Unit L-e'eckS r m Zone Overlay District O l D Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 IOwner of Record: /VGI n w C N.22(je cs a3 an l Gt AJ- Name(Print) Current Mailing Addr s Telephone Signature 2.2 Authorized Accent: Sic 4 V-2 i�er F-t ow'z ►tit l�} t a. Name(Print) Current Mailing Address: �Ces; tkr 1M q13 'S86)- 8-6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COS rS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Iq (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of O C Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) Z � t:>C9 5. Fire Protection 6. Total= (1 +2,m+3+4+5) Ski SZ Check Number 011f IS rN This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date vKJ File#BP-2015-0124 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 URA(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 Typeof Construction: CONSTRUCT KITCHEN ADDITION,ADD DECK,REMODEL KITCHEN&LIVING ROOM 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 OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 Pen-nit 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 I— Delay 1 Signature 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. 23 UPLAND RD BP-2015-0124 GIs#: COMMONWEALTH OF MASSACHUSETTS MapBlock: I 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) Category: renovation BUILDING PERMIT Permit# BP-2015-0124 Project# JS-2015-000151 Est. Cost: $159525.00 Fee: $957.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. 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 MAO 1060 ISSUED ON.81712014 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT KITCHEN ADDITION (6 X 9), ADD 22 X 14 DECK, REMODEL KITCHEN & LIVING ROOM 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 8/7/2014 0:00:00 $957.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner