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24D-195 (9) LBUIDER- S SCOPE OF NVORK & Tviri Prf)spcct FSTIVAYLI) STAR I D.A-IV: 1,L. 2'.)I ; E'-s1 in-N 1 W1 N 1)()\V I N'S V RTS -1 his proposal includes the folhm 1 do It Jr1l:1� kli,, Jll i lill-l! INDM\ s (1.,N( I'l, DIN(; T.V,0: 2,279.U1) VABOR VIN 1) \1 1d(,- \IA I FRI 1,000.00 1,Rl(,V FOR J.,\130R \ND MATERIAL 53,279.00 DO Aof SIGN THLT t IN TR 1( F IF IWERE .IRE M Bt AAA SIT ICFS, THIS IS .1 LEGALL) B0006 . 16REVIlk"N T. It" 111FR& 1RE I \ Y PRO I jW(T\A; 11111(if MU DO NOT UNDERSTAA'D, 11EITER B1 JIMERS. INC. MN N EFR Ire. `:colt Kcitur, President Dw Daw 11F SWAM 1. R11 < "j- i ill P 1 ii AH( 1 )"i 1 M! I ( )I- l Hi. PAR W ) WITHIN KIN T DISKII �,I Ill 1 AlM 11j) RY I ill (UNi RACTOR. AAK ()\\ NLR MAN AITKTI \1 A MW W' Dl- '! 1 1= PJ'SIq [!A)\ FVl \ \\ I li RI: 1 i 11 SI_C -1()\ IS y:(-II \1 Fl.'l '-A All) BY I KIL 1, Un ii s, rm 111(fifl 1() I Nil I \ 1 i AL FERNAMT DISM I L Rl S()I 111O\ SHAT I I M) MWOMS VKH W Wil (A- llli5 VO TICE 1 ' ., qn\ \ 1 ( R!_ q oh w jF ini, j 11 N \fit Vi On! A kW ) 1( 1 lid \GRFF"P\ I ( A Hil- MR&I-S 1 ( ) W IF RN A H ASPI 11 51 1 11 1 Alk'N 1 1\1 I W I PL) BY 111E OA I RAC I OR Ff A UV NFR \K) 11 A I '\ 11\ 1 1)1�P( i 1 -;j �t )i_i AT)N F Vp% M!I RL SLCHOX� 1`i MOT 11 [- ) SRAI 1) BY 11T KAUTS. 1111 RKAH I 10 INARAll ALARKADVE LMSPI -Fl-. ] R)\ ti! LAI L LND OW )tWS JAR 111FDAH M THIS AWRITMEN1 . IHS(ELLIAEOIS: 1 is a tho agwai4Ti ho"wrt us. 3n\ reposmMon, w 2011tall-1,2d 11 !! A!-� !-It)., 11 of al]�! it 1> bindirl'Z7 upoll our and anmyrts 1 hi, \'VOLMON IYQ ho 1jolow oak h.% an hutrumcm in mrAing siyncd h\ NO 4 js J ,"0 J c11 t!1C Ck'Ltl of \\ollk for V, KlGlfl 10 C.4-\CTL CO\Th, IC I: V'\) C_'010 ! I !1: 11- hN NOWD [II) A PAITI Y I HL RK"D 3N \kj)t\(j )!9*1? A! L\_1 QQ 1 ! A(i 11) . \1'-\1! 13Y Al PURAM S1.111 OR H) DC_[ ARY " ! I GFR OW, MIDNAIM OF Mh 1111M RrSJNLS-, HKAp" IliG jill! 1115 .ViRFF\11 V . 1 1 C 1, [ 'A 1)J )I1 ina si( 11-d Z thi AZ71i.Cmcw !"a' 7�C ,I,)v7 AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/10/2015 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 NAME: y Webber & Grinnell PHONE (413)586-0111 FAX (413)586-6481 S10 fja)__ A/C No): 8 North King Street ADD RIESS:chenderson @webberandgrinnell.com ----- --- r --- INSURER S AFFORDING COVERAGE NAiC# _ Northampton MA 01060 - INSURERAArbella Insurance_Grou 17000 INSURED INSURER B: Keiter Builders, Inc. -INSURER C: Attn: Scott Keiter INSURER D: 35 Main Street INSURER-E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Exp 2016 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 SUER POLICY NUMBER MOLID/YYYY P /Y LT M/DDYYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY 1,000,000 ___ EACH OCCURRENCE $ j DAMAGE TO RNTE A �� CLAIMS-MADE ❑X OCCUR PREMISES EE a occuD rrence $ 300,000 8500064396 6/1/2015 6/1/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE - $ 2,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 -- OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 h Ea accident ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS X AUTOS 1020039381 6/1/2015 6/1/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS X AUTOS Per accident) $ rX Medical payments $ 5,000 X UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ 1 000 L00 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1 000 000 X 4600064399 6/1/2015 6/1/2016 $ TH- DED RETENTION$ 10 000 WORKERS COMPENSATION X 1 PER E OR- AND EMPLOYERS'LIABILITY STAT TE ER ANY PROPRIETORIPARTNER/EXECUTIVE Y/N EFEL.L EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? � N/A A (Mandatory in NH) 9127440615 6/11/2015 6/11/2016 DISEASE-EAEMPLOYE $ 100,0_00 If yes,describe under DESCRIPTION OF OPERATIONS below DISEASE-POLICY LIMIT $ 500,000 i i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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. AUTHORIZED REPRESENTATIVE C Henderson, CISR/CIN ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSn96 r9ntan11 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 1 Congress Street,Suite 100 �W Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): GQi(`�' 6o L4, W lG(,C Address: Ata (A �-- City/State/Zip: Phone #: &-r:;- GZ� Are you employer? Check the appropriate box: Type of project (required): 1. am a employer with �� 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑ New construction 2.❑ l 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 or me in an capacity. employees and have workers' g y p y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. F1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13. Other W htt S comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. � 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: Policy #or Self-ins. Lic. #: �pti�' K��(-� t Expiration Date: tj 1l 1 Job Site Address: 1 3 L' 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 tine 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 cer y under the ains and penalties of perjury that the information provided above is true and correct. Si nature: �► O/rt._Date: (�/a-�!� Phone #: ,�� E12 C ) 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#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of IVIGL 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: -3 7L The debris will be transported by: �'!� r The debris will be received by: jzA4 4fz�, Building permit number: Name of Permit Applicant , cf Date U Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructions Supervisor- Not El Applicable Name of License Holder:. ��`T F-��` `v ► C- ( 0 C? l �" License Number ate Addre �� Expiration D cV\ oo ign to Telephone 9.Reaistere me Intnrovement Contractor, Not Applicable ❑ � w1 8 ,&AlLrs lL-c 1 Company Name Registration Numbe 3 s 51+ `�- Address rl /1 Expiration Date faO&CLA U Telephone 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 buildia permit. Signed Affidavit Attached Yes.......1K, 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 W ws Alteration(s) ❑ Roofing ❑ Or Doors [1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[E3] Brief Description of Proposed ,/ Work: r e 3 ) 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 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 I, P�' �rf.� as Owner of the subject property 1 hereby authorize ` I �� 1 to act on my behalf, in all matters relative to work aut orized by this building t application. d'gaiz Sze, &' lding per C.,+W"+ Sign ure of Owner Date I, �°/ flit/► /d(..� 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 pen Ities of perjury. swAA law Print Na l e4 y natu e oTOM r gent 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 Q� YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis y 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 Q DON'T KNOW (D--YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO C�, � 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 Q� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only N iffEIVEQ ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit OCT 4 2015 212 Main Street Sewer/Septic Availability ROOM 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans DEPT OF ,_D+ NSP IE 0 rn TN, =7700,MA "L 41 -587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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: 15-3 Map Lot Unit Zone Overlay District Elm St.District; CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: P. 71 Cf Ve l Ct4k ��3 Pry' (34 Name(Print) (( Current Mailing Address: 0 cS� '5/ at tw,(- Telephone �gnature 2.2 Authorized Agent: Name(Pri Current Mailing Address: Sig at e I Telephone SEC ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 2 (� (a)Building Permit Fee 2. Electrical `7 (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) U7 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: — Building Commissioner/Inspector of Buildings Date 153 PROSPECT ST BP-2016-0504 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D- 195 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-2016-0504 Project# JS-2016-000842 Est. Cost: $3273.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 7884.36 Owner: O'NEIL THERESA A&PAMELA J COPELAND Zoning: URC(100)/ Applicant: KEITER BUILDERS AT. 153 PROSPECT ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON:10/14121015 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 Denartment 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 10/14/2015 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner