32C-078 (4) 14 CONZ ST BP-2017-0035
GIs n: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-078 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
Permits BP-2017-0035
Projects JS-2016-002673
Est. Cost: $145000.00
Fee: $1015.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITER BUILDERS 102457
Lot Size(sq.ft.): 7579.44 Owner: KEITER SCOFF
zoning: uRC(10o z Applicant: KEITER BUILDERS
AT: 14 CONZ ST
Applicant Address: Phone: Insurance:
35 MAIN ST (413) 586-86000 WC
FLORENCEMA01062 ISSUED ON:7/18/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:MI SC INTERIOR RENOVATIONS
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 tt 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:
FeeTvpe: Date Paid: Amount:
Building 7/18/2016 0:00:00 $1015.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-0035
APPLICANT/CONTACT PERSON KEITER BUILDERS
ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 O
PROPERTY LOCATION 14 CONZ ST
MAP 32C PARCEL 078 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid OC t� �] Ia<- k /7 olE
Building Permit Filled out
Fee Paid
Tvoeof Construction: MISC INTERIOR RENOVATIONS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102457 f
3 sets of Plans/Plot Plan /"'(41 Time
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR�MATION PRESENTED:
J/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
'Demolition Delay
`� ie 7x//6
gato :m ding O'icial 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.
Version1.7 Commercial Building Permit May IS,
REC�c ,r Department use only
City of Northampton Status of Permit:
Building Department Curb Cut(Oriveway Permit
!� 2 Lutb I i 212 Main Street Sewer/Septic Availability
Room 100 WatenWell Availability
OF liUItDlHcwsPrLtIDHs �Jorthampton, MA 01060 Two Sets of Structural Plans
aNORTHAMPTON.MA 01060
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION it
o //?c,/ i/Gti/S
1.1 Prooertv Address: This section to be completed by office
Map Lot Unit
14 Conz Street
Northampton. MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Scott Keiter 5I A Hatifeld St Northampton, MA 01060
Name(Print) Current Mailing Address_
it ���/// 413-320-9035
Signature Q"` Telephone
2,2 Authorized Agent:
Keiter Builders,Inc 35 Main St Florence,MA
Name(Print) Current Mailing Address:
�7 413-586-8600
Signature it y� pre.,„,„,. ,,viler IAi Oder,. inc. Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $75,000 (a) Building Permit Fee
2- Electrical $20000 (b)Estimated Total Cost of
Construction from (6)
•
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) $50,000
5. Fire Protection _ -v
6. Total =(1 +2 +3+4+5) $145,00.00 Check Number 6 /41,5 /r 0/3'
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date CEI p/fE�D
a i2CND
PEP6 or eu'L'ING Vitt—�:v,�.
Version 1 7 Commercial Building Permit May IS,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑✓ Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs 171 Roofing❑ Change of Use❑ Other❑
Brief Description Misc. interior renovations. See attached plan
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F'2 ❑ 2C (,
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B n
M Mercantile ❑ 4 n
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify.
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group. Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
a 1m
2nd 2a
3rd
3°
4h 41h
Total Area(sf) Total Proposed New Construction(sp
Total Height(0)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public n Private❑ Zone Outside Flood Zones Municipal❑ On site disposal systems
Version).7 Commercial Building Permit Mac 15,1000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be idled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage 9r
)Lot arca minus bldg h pa'ed
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version I.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant).
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibiity
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Keiter Builders,Inc.
Not Applicable El
Company Name:
Scott Keiter
Responsible In Charge of Construction
35 Main Street Northampton NIA
ess
4135868600
President, Keifer Builders, Inc.
Signature Telephone
Version 1.7 Commercial Building Permit May 1 5,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No O
SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Scott Keiter
I, , as Owner of the subject property
Keiter Builders, Inc.
hereby authorize to
a onmynf, in all matters relative to work authorized by this building permit application.
07.11.16
Signature of Owner Date
Keiter Builders, Inc.
,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.
Scott Keiter
Print
/i`r-6Cf 07.11.16
I'u siJrnt,
Keiter Builders,Inc.
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10,1 Licensed Construction Supervisor: Not Applicable 0
Scott Keiter CS-102457
Name o1 License Holder
License Number
51A Hatfield St 06/20/16
Ad{less Expiration Date
SOL(_/A- 4135868600
I`ra�iJenh 6citcr IArildcr.. Inc.
Signature Telephone
SECTION 13-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 0
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: 14 Conz Street
The debris will be transported by: Duseau Trucking
The debris will be received by: Valley Recycling
Building permit number:
Name of Permit Applicant Keiter Builders, Inc
07.11.16 �G✓✓L, rr.detm. '<titer Builders,Inc.
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ei UM Office of Investigations
va _ 1 Congress Street,Suite 100
r1= Boston,MA 02114-2017
Mem www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Keiter Builders, Inc.
Name (Business/Organization/Individual):
Address:35 Main St
City/State/Zip:Florence, MA 01062 Phone 4:413-586-8600
Are you an employer? Check the appropriate box: Type of project(required):
1.8 I am a em to er with 1 6 4. 0 I am a general contractor and I
P y 6. 0 New construction
employees (full and/or pan-time).` have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the anached sheet. 7. 5 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. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing al work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] '1c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box ft I must also fill out the section below showing their workers'compensation policy inlonnation.
Homeowners who submit this atidavit 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:Arbella Insurance
9127440616 6/11/2017
Policy#or Self-ins. Lic. #:_ Expiration Date:
14 Conz Street Northampton, MA ()-
Job Site Address: 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 rtify un er t pains and penalties of perjury that the information provided above is true and correct.
07.11 .16
Signature: Date:
Phone(4: 413-586-860C
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACORne CERTIFICATE OF LIABILITY INSURANCE �IELM 016 '
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: 11 the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. It 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, CSSR
Webber S Grinnell IPHONE cep. (413)586-0111 '.1AAX NN (419)986-eael
/ALL LA,8 North King Street qu0Fc95:chendersonewebberandgrinnell.com
_. INSURERISI AFFORDING COVERAGC _ NAICL
Northampton MA 01060 INSURER AArbella Protection ' 41360
WSUREO INSURER B: _
_✓--.. __
Netter Sunders, Inc. IxsDRET9c :.
Attn: Scott Keiter INSURER o:
35 Main Street INSURER E:
Florence MA 01062 INSURER F'. - -_ --
COVERAGES CERTIFICATE NUMBER:Master Exp 2017 REVISIONNUMBER:
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.
INSP. INsrl VIVO POLICY NUMBER I MMN%IYYYVII imnWpayXP I LIMITS
LTR TYPE OE INSURANCE I POLICY,ESP I
X COMMERCIAL GENERAL LIABILITY •
EACH OCCURlENCE ,5 1,000,000
.DAMAGE TO htNTED
A _ -CLAWS-MADE XOCCUR - PR EMISEIERMWrtOCt} 15 ,, 100,000
B5000642 P6 16/1/2016 16/1/2017 MED EXP(Atone Person) ''.$ 5,000
IPERSONAL d ADV INJURY '5 1,000,000
r �_._..
!SENS AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE 5„ 2,000,000
. x IPOGC.Y PRO- LOC PRODUCTS.COMP/OP AGO S 2,006,000
_ 'JECT _.
•
OTHER
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY COMBINED
acceem $ 1,000,000
ANY AUTO 80DILY INJURY MAL person) $
LLOV4NED SCHEDULED
gTOS 'T MHOS 1020039213101 6/1/20{6 6/1/2011 600 INJURY(Per accident) 9
NON OWNED PROPERTY DAMAGE
X HMSO Auras X AUTOS (Per a'c,MER) 5
I , Med'cal Paymwtl I5 5,000
X ''.UMBRELLA UAB
OCCUR I EACH OCCURRENCE I5 _ 5,000,009
A i
EXCESS LIAa CLAIMS-MADE' AGGREGATE 8 5,000,000
..
r�
DEC I X RETENTIONS 30.000E 4600084399 6/1/2016 6/1/2017 I 8
CAiRS LI A TO X 5 RT1±]E X I.ERH
ANO EMPLOYERS LIABILITY Y/X — —_....
ANY PROPRIETOR EXCLUDER,
EXELUTIVE N N/A E EACH ACCIDENT I5 1,000,005
A
OFFICER/MEMBER Me E%CLV O N 91274406/5 6/11/2016 6/11/201'/
IMesdeI'MNX1 E DISEASE EA EMPLOYEEE 1,000,000
If yeioeseAkm under
DESCRIPTION OF OPERATIONS ARIA* LEL.DISEASE-POLICY LIMIT 8 1,000,000
•
. _......_J
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks S(M1adule,may be aNCM1W it more space b Newe61
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL LED BEFORE
For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATWF
C Henderson, CISR/CIN 5 p w "eare—"
C1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(20141)t} The ACORD name and logo are registered marks of ACORD
isiOn95,aT.yv+
KEITER
BUILDERS35 Main Street•Florence•MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilderscorn
Commissioner Hasbrouck 07.11.16
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the 14 Conz Street
Renovation Project in Northampton because the work is of a minor nature,will not affect health,accessibility, life and
fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when
compared to the cost of the proposed work.All work will be completed within the prescriptive requirements of 780
CMR.Thank you for your consideration.
"Mass Amendments,sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
'14 / P,.*y, t_,,
Scott Keiter
Keiter Builders, Inc.
35 Main Street
Northampton, MA 01060