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10-023 (5) 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: k6al led5 "A- 0/653 The debris will be transported by: The debris will be received by: Building permit number: Irl Name of Permit Applicant ��-�7--eV /IL Date ignature of Permit Applicant STORAGE ROOM February 19,2015 cost Vapor Barrier Below Corxxete Insulation 0.110 RENDING REVIEW Doors 2,600.00 Exterior Doors (2)36'fiberglass exterior doors with hardware. $600 allowance per door, KVAG Affowanca.$,30(1,00. Reiocate mim items a, Electrical 750.00 Electrical ALLOWANCL:$600.00 Slab Preparation Minor excavation. laser. Prepare for r iew slab. Dispose of any excess fill onsoe. Project Total 13,100.00 Tax 181.55 Total With Tax 13,281.65 We appreciate your business and loo forward to working with you. Approved By: Date: 3' •/S� �- Date: r1� Contractor d• _._. Customer Lt Keller Builders,Inc.,License#:102457 3 STORAGE ROOM February 19,2015 Scott Leiter ti a Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Office 413.566.8600 KEITER Fax 413.284.0124 NBUILDERS,scottkeiter @gmail.com www.KeiterBuilders.com License#: 102457 Pra/ect Customer STORAGE ROOM I Howard& Dianna Smith j 441 Kennedy Road (i 441 Kennedy Road Leeds, MA 41053 ? Leeds MA 01053 REMODEL EXISTING AREA TO BECOME STORAGE r---,-- _............. ' Description Cost Debris Remove! Demolition Ground Protection Plywood, Protect grass from machine Materials Running Mobilization Permits Portable Toilet Work Isolation M E, Concrete Gutting (2)Door locations Concrete Disposal TranWrt using T850 into dump. Transport to Bill Wiliaras Concrete Slaty 4"slab. Wire mesh,3 cubto yards. Standard finish T 660 whopper Transport,Orator General Carpentry 1;431.25 Create Opening for Exterior Door Frame4n new exterior door Plywood on Walls Install 112'GDx at walls Keiter Builders,Inc.,Llaense#:102457 2 STORAGE ROOM February 19,2015 KF E,I T i-i r-Q"" BU ILI I LD ER t(1 IIY�GVdl�ill��r,pe,�,i�,a , s a g, STORAGE ROOM 441 Kennedy Road Leeds, MA 01053 Submitted by: Scott Kelter eiter Builders, Inc. 35 Main Street Florence, MA 010162 Office:413.586.8600 Fax: 413.280.0124 scottkeiter@gmaii.com ww,KeiterBuilders.com License#: 102457 Keiter Builders,Inc-License tf:102457 1 l ® DATE(MM/DD/YYYY) AC"° CERTIFICATE OF LIABILITY INSURANCE 12/10/2014 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). CONT PRODUCER NAMEACT Cynthia Henderson, CISR _ Webber & Grinnell PHONE (413)586-0111 FAX .(413)586-6481 8 North King Street E-MAIL .chenderson @webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC A 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 INSURERD -- 35 Main Street INSURER E: Florence MA 01062 1 INSURER F: COVERAGES CERTIFICATE NUMBER 1°taster Exp 06/15 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 I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVQ POLICY NUMBER M/DD/YYYY M D/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A -� CLAIMS-MADE X� 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 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ECT AUTOMOBILE LIABILITY Ee .c AUTOMOBILE LIMIT 11000 000 BODILY INJURY(Per person) $ B ANY AUTO ALL OWNED X SCHEDULED BCDR07 12/21/201412/21/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS —— PROPERTY DAMAGE X HIRED AUTOS X AUUTOS�ED Per accident $ Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ C WORKERS COMPENSATION X WC ' MIT7 OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A IEUS2A56578214 6/11/2014 6/11/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 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 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INCn7r,r?ninnsini Tl+n Arr1Rr1 Inner of Arnon The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations d 1 Congress Street,Suite 100 Boston,MA 02114-2017 N Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r Please Print Legibly Name (Business/Organization/Individual): �I��i -- UI Address: J5 114 4IN ST-R&G — City/State/Zi : r—LQ MA-61*Z- Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.W1 am a employer with q 4. ❑ I am a general contractor and I 6. F-1 New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. 6 Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ 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 q�, employees. [No workers' 13.[� Other HDVA nN4 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 and job site information. i Insurance Company Name: Policy#or Self-ins. Lic. #: S �U Pj2�Jr(o5� Z(�} Expiration Date: /6 Job Site Address: 44) City/State/Zip: LELQ5, M� x1053 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 Investigation of the DIA for insurance coverage verification. 1 do hereby)c 7* ntZre ains and penalties of perjury that the information provided above is true and correct. L C. te: 3 / 6- l 5 St nature: �. K E 1 IZ Da Phone#: ���' S��— �'�oOb 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 Supervisor: Not Applicable ❑ Name of License Holder:- SC DTT h�auL 1/�5 — /0 Z 45 l—7 License Number �� A �a��i>olol oaf D�ov a-W 12 r 94 - dlDfoO (a - 20 - ZdRo Addr ss Expiration Date (0&0 g ture Telephone 9 Reai +ered Horn®Imbrovement Contractors: Not Applicable ❑ Company Name Registration Number 35 f'�'I GLin �. > DVe c e /(it 0 I0 /� q Z 0 Z o ) 7 Address o Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L1 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 buil ing permit. Signed Affidavit Attached Yes....... No...... ❑ 11 - Home Owner Exemotion 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 anolicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing El Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [C) Siding[0) Othe Brief Description of Proposed / // — L Work:VNVt"Ad PA[�5�iv�4S bas e..,na� r&V-A 4b a ✓eug ✓corn IV X Alteration of existing bedroom Yes _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 fvllowina 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 /pt",r-=. G , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing apple ation are true and accurate, to the best of my knowledge and belief. Sig ed under the pains and penalties of perjury. Print Name 2 /_ Signatur er/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 0 YES IF YES, date issued: 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 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 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 only ity of Northampton Status of Permit'` uilding Department Curb Gut/privew Permit 212 Main Street Sewer/Septrc-Avatdabir-J, Room 100 Water/ ell Avoila.bi'y ' 162015 hampton, MA 01060 TwoSefis of Structural 'tans hone 13 587-1240 Fax 413-587-1272 PIot/SitePlasl Electric, Plumbing&Gas Irises Other Specify, h m to APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: I/q l K.e n 90 Map Lot Unit Lz td q' M A— 0/6,55 Zone Overlay District Elm St.District - CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /�- ✓a+ aGt ln0( 7t'l Name(P(nt) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: e/ tin u l de✓:5 c- 5 �?�i n S fve �-� ✓�vi c 2 �/I Name rint) Current Mailing Address: q/3 5F/P-8looa Si n tune Telephone SEC ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (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= 0 +2 +3+4+5) 2 $ Check Number This Section for Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0856 APPLICANT/CONTACT PERSON SCOTT KEITER ADDRESS/PHONE 51A HATFIELD ST NORTHAMPTON01060(413)586-8600 Q PROPERTY LOCATION 441 KENNEDY RD MAP 10 PARCEL 023 001 ZONE RR(100)/WSP(100)/WP(13)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid iypeof Construction: REMODEL BASEMENT ROOM INTO STORAGE 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO jMATION 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 Signat a 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. 441 KENNEDY RD BP-2015-0856 GIs#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 10-023 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:renovation BUILDING PERMIT Permit# BP-2015-0856 Project# JS-2015-001672 Est. Cost: $13282.00 Fee: $79.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sa. ft.): 375443.64 Owner: SMITH DIANNA Zoning: RR(100)/WSP(100 /L13)/ Applicant. SCOTT KEITER AT: 441 KENNEDY RD Applicant Address: Phone: Insurance: 5 1 A HATFIELD ST (413) 586-8600 WC NORTHAMPTON MA01060 ISSUED ON:311712015 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL BASEMENT ROOM INTO STORAGE 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 3/17/2015 0:00:00 $79.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner