18C-123 (3) ESTES January 20,2015
iE
Windows
New Construction Windows(5)
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•instaa Pena tape at nal"nn$
instak now PVC exterior brick mold trim
Instal new PVC appted mg to mnun fty;I 19
in"new ff&Ax tnm M ntalfn Lxi`A mg
•
Exclusions
•Prune,palms 11x11 f'—we nZnq.CI Ome(NI'V1es
Notes
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Project Total 8,400.00
1
Date: t20%t5 Dater
Approved By' _ _ _..__..-
Contractor �� � Cuslome
Kotler Builders.inc.,License 102457 2
ESTES January 20,2015'
Keifer Builders, Inc. SCOPE OF WORK
35 Main St.
Florence, MA 01062
Office 413.586.8600
Fax 4 t 3.280.0124
scottkeiterOgmait.com B U I L D E R S
www.KeiterSuilders.com
License#: 102457
Customer
ESTES Emily Estes Office 413-585.0641
19 ALLISON STREET 19 Allison Street Mobile 413-320.6199
NORTHAMPTON, MA 01060 Northampton. MAO 1060 emily @tdouglasarehitects.com
WINDOWS
Notes:
Estimated project length is one week
Dacerl}14lcxr Colt
MIN
r t Ir
General Administration
Permits
Silo Set-Up S Breakdown
Staging and Ladders
Waste Removal
Work Isolation
r"encicuffe•ai vwa i,kFPA Vac
Windows _11'00
'
Inserts(10)
Hemnve:ano omposo a,eustlxq usn vests
Remove.aye Qsooso of.Storm wtrnJoµun
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Keiter awiders,InC.,LiconSe t: 102457 i
lK.EIT U DERS, INC. OWNER
rt K iter,President Date Date
Date
NO.TIfr'E:
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO TIIE AGREEMENT OF THE PARTIES
TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY TI Ih CONTRACTOR. THE OWNER MAY
INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT
SEPARATELY SIGNED BY THE PAR'T'IES. THE RIGHT TO INITIATE ALTERNATIVE DISPUTE
RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THIS AGREEMENT'.
1VOMg:
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO'11111 AGREEMENT OF THE PARTIES
TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY 'I HE 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 T FIL'• DATE OF THIS AGREEMENT.
MISC LANEOU.S:
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.
Owner understands and acknowledges that Keitcr Builders, Inc. may use any photos taken during the course of
work for promotional purposes. This may include, but is not limited to. the following: Websitc, newspapers,
journals,magazines,posters,and Ayers.
RIGHT TQ 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 MIDNIGIIT OF THE THIRD BUSINESS
DAY FOLLOWING THE SIGNING OFT HIS AGREEMENT.
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: lq '*Vj
The debris will be transported by: �Zj � g1,4 j6ejV S 1AC,
The debris will be received by: v
Building permit number:
Name of Permit Applicant
6
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
WL 1 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):
Address:
Cit /State/Zi : �J', _e4A d/C�'j�Phone #: /� 61 69-6
Are you an employer? Check the appropriate box: Type of project(required):
1. 1 am a employer with__1 _0 4. ❑ I am a general contractor and 1
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 1 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 for me in any capacity. employees and have workers'
9. Building addition
[No 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 1 l.❑ 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 n ✓Q
employees. [No workers' 13. Other f�l Y1k
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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: 1 YU(10665 /i?,S t r-A-`7 �
Policy#or Self-ins.pL,iic. #: TE(46g:2l 46-65-��d-1 Ll Expiration Date: 6 • l ( l SJ
Job Site Address: /0/ IiIIISdn S71/�2 City/State/Zip:,,t),dy-44Cltki�;kM, Ct4 O106a
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 certi y under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: B61 e4 �Gt���ors �kG Date: / �6• �J
Phone#: W3 5-56 ZrC.Ct7
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�Su_oer isor: ` Not Applicable Li
Name of License Holder: fJ'�'T [�-C 1 J— CS— to a, Lt Y`4
License Number
SA-
Addre Expiratiod Date
otVature Telephone
8 Reaistered'Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Dat
Telephone Sh6 S660
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 buildin 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)
New House Addition Replacement Wi6dows Alteration(s) El Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding[❑] Other[E3]
Brief Description of roposed
(
Work: YPOa CA'r-k LA3
Alteration of existing bedroom Yes o Adding new bedroom Yes V-IX
No
Attached Narrative Renovating unfinished basement Yes _--No
Plans Attached Roll -Sheet
6a. if New house and or addition to existing housing comatefe the fallowing
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, 0—m °U `-'S as Owner of the subject
property
hereby authorize `t�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Q-e aA cx-CL41 i ltk CA1\k CV—C
Signature of Owner Date
1, `�� "" ` S r I 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.
Pnnt ame
Q icCu ktf ✓ tl I�t,c, ! 1
ign ure 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/Finding 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 Registry of Deeds?
NO 0 DON'T KNOW tz YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 01" DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained l 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 l 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 I NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i `
Department use only
of Northampton Status.'af Permit
Q. (ding Department Curb Cutlpriveway Permit
12 Main Street S uer optic Auad ►liky
Room 100atertWell Availabttir.
-Na Illmpton, MA 01060 Two ets of Structural Plan
phone 413-587-1240 Fax 413-587-1272 PIotISi>e Pleris'.
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
rr
pq Map Lot Unit
QCO6 d Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1 \q S �e e4 � br a
Name(Print) Current Mailing Address•
,see a c�P,Q � c vA- � l3 32c �t Rte(
5 S� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:F(605
i �- t&,��ldfcs IK� `113 S"x6 6
�a
ig ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / 01 , C)o (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
Building Permit Number: Date
Issued:
Signature'
Building Commissioner/Inspector of Buildings Date
19 ALLISON ST BP-2015-0758
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 18C- 123 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-0758
Project# JS-2015-001471
Est. Cost: $8400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT KEITER 102457
Lot Size(sq. ft.): 7710.12 Owner: ESTES EMILY
zonine:URB(100)/ Applicant. SCOTT KEITER
AT. 19 ALLISON ST
Applicant Address: Phone: Insurance:
5 1 A HATFIELD ST (413) 586-8600 O WC
NORTHAMPTON MAO 1060 ISSUED ON.112612015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 10 REPLACEMENT WINDOWS
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 1/26/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner