32A-140 (4) 109 MAIN ST BP-2017-0352
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 140 CITY OF NORTHAMPTON
Lo: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:demolition BUILDING PERMIT
Permit# BP-2017-0352
Project# JS-2017-000579
Est Cost:$2000_00
Fee; $100,00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
UeGrouo� KEITER BUILDERS 175168
Let sizetse. ft.); 11325.60 Owner: NiS BUILDING LLC C/O HPMG
zoning:CE(tooy Applicant: KEITER BUILDERS
AT: 109 MAIN ST
Applicant Address: Phone: Insurance:
35 MAIN ST (413) 586-8600 O WC
FLORENCEMA01062 ISSUED ON.•9/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:SELECTIVE INTERIOR DEMOLITION TO ALLOW
MECHANICAL ENGINEERS ACCESS TO REVIEW
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 if Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 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 9/16/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0352 //�J0 t f//'�C
APPLICANT/CONTACT PERSON KEITER BUILDERS w /'"�l W�J
ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 0 �k"'J�,,,..•�
PROPERTY LOCATION 109 MAIN ST
MAP 32A PARCEL 140 001 ZSN,. CB 100
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATIONNCHECKLIST
ENCLOSED REQUIRED DATE
ZONINci FORM FILLED OUT
Fee
Budin Permit FiilGd out or vi/ T le VrV
Fee Paid
Typeof Construction: SELECTIVE INTERIOR DEMOLITION TO ALLOW MECHANICAL ENGINEERS
ACCESS TO REVIEW
New Cuns[mction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 175168
3 sets of Plans I Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
stide,Si_-: i reofBuilung 0 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.
VersionI 7 Commercial Building Permit Ma) 15.2000
"" Department use only
I — . - City of Northampton Status of Permit:
1 <rY 8 , Building Department Cum Cut/Driveway Perrot -
( 212 Main Street Sewer/Septic Availability
I Room 100 WaterAVell Availability
ma
orErca :nu•J Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PbVSiie 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
1.1 Property Address- This section to be completed by office
109 Main St Map Lot Unit
Northampton.MA 01060 zone Overlay District
O Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
\ q
Owner DI Record: �a/YS N4?. /d/.• b �L� /Ci.. „7•1Z2,,,, (1,-„:„„„ 1 y?co Jry d<E6
I ��..� �_ 4.4,,,-d/, ,. s,,,i,/,-,, ;w/-/ C�rc6/
`"1 Name(Print) S��tf,� / co i'I G -,-C-`"ori - Current Mailing Andress: )
Signature -1 _< . E '��-"v'l. y]S C,�/P.ICie, Telephone 4� ,ri// 3/ J r�' -r C2 -c
2.2 Authorized Agent:
Keiter Builders.Inc. 35 Main St Florence, MA01062
Name iPvnt Current Mailing Address_
413-586-8600
Signature Prt.idenI. kin Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2 Electrical Co)Estimated Total Cost of
Construction from(6)
3 Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Fire protection # s //-// f,
6. Total = (1 +2 +3+4+5) . ( (J 0 Check Number �r�
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspeolor of Buildings Date
Version L7 Commercial Building Permit May 15.2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition❑ Repairs❑ Additions 0 Accessory Building❑
Exterior Alteration 0 Existing Ground Sign❑ New Signs❑ Rooting❑ Change of Use❑ Other
Brief Description Selective demolition to allow mechanical engineers access to review
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE PLEASE SEE THE ATTACHED CONTROL DOC
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-I ❑ A-2 ❑ A-3 ❑ 1A � ❑
A-4 ❑ A-5 0 19 0
B Business ❑ 2A ❑
E Educational 0, 2B I 0
F Factory ❑ F-1 ❑ F-2 ❑ .�...— 2C n
H Hit Hazard 0 3A 0
I Institutional ❑ I-1 n -2 ❑ 63 ❑ 3B
M Mercantile 0 4 (l
R Residential ❑ R-1 f] R-2 0 R-3 ❑ 5A ❑
S Storage 0 ST 0 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 3411
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Row(sf)
151
in
2n°
2aa
3ra 3,a
4Th
4m
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40.§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Pubiic • Private • Zone Outside Ftood Zones I Municipal 0 On site disposal systems
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
l hie column to be filled in try
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L:_ R:_ _
Rear
Building Height
Bldg,Square Footage 7.
Open Space Footage 9 �--
([rg ore r minas Ndg&pared
parking)
#of Parking Spaces
Fill:
(volume&tenni...._ _
A. Has a Special Permit/Variance/Fin�ding ever been issued for/on the site?LJ
NO 0 DONT KNOW YES a
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document //
B. Does the site contain a brook, body of water or wetlands? NO V 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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE'_ O 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).7 Commercial Building Permit May IS.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:
Thomas Douglas Not Applicable 0
Name(Registrant):
Thomas Douglas Registration Number
Address .......
Expiration Date
Signature Telephone
9,2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Si.nature Telephone Expi aeon Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibibly
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Keiter F3uilclers, Inc
Not Applicable❑
Company Name:
Scott Keifer
Responsible In Charge of Construction
35 Main St, Florence, MA 01062
A ess
preybdrm.fltot 413-58G$600
Signature Telephone
Version I.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No •
5OWNER AUTHORIZATION-TO BE COMPLETED WHEN
00710ER'3`AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. Qt CNdfi.> 1tV/A17otN't i as Owner of the subject property
Keiter Builders, Inc.
hereby authorize to
act on my behalf, in all mattcrs relative to work authorized by this building permit application.
(mak .-„L., V's /bk .lq Fite. . (( v
Signature of Owner 7rl-.y„�- r3... ! cf t.�5 L it Date
Keiter Builders, Inc
1. , 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
.p(p/{jSccotttt�/Kei ter
U am '” _........
Pi-editing.rut to
08.01.16
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
)0.1 Licensed Construction Suoerviso[: Not Applicable 0
Scott Keiter CS-102457
Name of License Holde['.
License Number
51 A Hatfield Street Northampton, MA 01062 06/20/2018
A ess ............
Expiration Date
Prefident, h61 413-586-8600
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(mai_c. 1$2,§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 MOL 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: 109 Main St Northampton
The debris will be transported by: Keiter Builders, Inc.
The debris will be received by: Valley Recycling
Building permit number:
Name of Permit Applicant Keiter Builder, Inc
08.01.16
Date Signature of Permit Applicant
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
- — 1 Congress Street,Suite 100
1'' Boston,MA 02114-2017
t✓� www.mass.govfdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Keiter Builders, Inc.
Name'Business/Organization/Individual): _ __
Address:35 Main Street
City/State/Zip:Florence, MA 01062 Phone ;;:413-586-8600
Are you an employer? Check the appropriate box:
I.® I am a employer with
4. 0 I am a general contractor and I Type of project (required):
18
employees(full and/or part-time).* have hired the sub-contractors 6, 0 New construction
2.0 I am a sole proprietor or partner listed on the attached sheet. 7. ii Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp.insurance.'
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGI.
12,0 Roof repairs
insurance required.) w c. 152.§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.)
*Any applicant hat checks how#I mast also fill out the section below showing their workers compensation policy information.
'I lumemmers 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 lune
empl@ixa lithe sob-contactors have cmpioyees.they must providetheir 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.AftJella Protection
Policy#or Self-ins. Lir,. #:9127440615
Expiration Dale:6!1/17
109 Main St Northampton
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 MGI... c. 152 can lead to the imposition of criminal penalties ofa
tine up to $1,500.00 and/or one-year imprisonment. as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby rtify under the pains and penalties of perjury that the information provided above is true and correct.
09.14,16
SS'i(hnalure: President. Kill Date'
Phone s: 413586-8600
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License P
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: „-, Phone II: ,,
ATE
A� CERTIFICATE OF LIABILITY INSURANCE n6ri9Aisn16 I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: II the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
CONTE
PRODUCER CONTACT Cynthia Henderson, CISR
Webber 5 Grinnell FNM�O. (433)586- 1A(.,x l
PHONE 0111 FAX ({t61566_64tlt
8 North King Street EMAIL chenderaonewebberandgrinnell.com
POpRtSC.
INSURER($}AFWROING COVERAGE j AMC t _
Northampton MA SU
01060 INSURER AArbel la Protection 91360_
__.
INSURED ,Ix5V11ER B: _..
R¢iter Builders, Inc. xSVRERC___-
Atta: Scott Ksiter xsuneR4
35 Main Street INSIDERe•
.
Florence HA 01062 mace F: _
COVERAGES CERTIFICATE NUMBERsaster Bap 2017 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 ASIA snarl . POLICY EFF POLICY EXP
LTR TYPE Or INSURANCE Ix50iVVOr„ POLICY NUMBERIMMO0NYYYI IMM�NYZTYII LIMITS
•X 'COMMERCIAL GENERAL_LM&tAiY EACH OCCURRENCE 5 1,009,000
A CLAIMS/MADE
ED
X OCCUR DAMAGE TO RE 'IED
r.PRSA SFS(EsSND'_Cos- g 100,000
•!
I ' 8500064396 6/1/2016 6/1/2031 NEDEXP{art ups m-RNA $ 5,090
PERSONAL 6 ADC INJURY $ 1,000,000
OF MI AGGREGATE LIMIT APPLES PER '(GENERAL AGGREGATE 5 2,000,000
X `POt C/ l LOC PRODUCTS', PRODUCTS COMP/OP AGO{5 2,000,000
OTHER $
COMBINED SINGLE LIMB � -
AUTOMOBILE LIABILITY ;WANG IFIN a 1,000 ,000
AUTO BODILY JURY( pereU J $
AM OWNED SCHEDULED
AUTOS X OTOS 102003938101 6/1/1016 611/201P B00 INJURY IP cc,C nl 9
% HTREO AUTOS S AUT ONNiLP (POI FATY D AGE- •S
AUTOS Me m a _
MCJ C„Mluton0 E 5,000
—,X UMBRELLA LIAR II
OCCUR I. � IEACH.^.CCtRRk NCE_ _ 5 5,400,000
A EXCESS LAB CLAIMS/MADEI AGGREGATE E 5,000,000
– X DECDEO : ESflUDONS 10,000 ' 4600064399 6/1/2016 6/1/2011 p
WORKERS COMPENSATION K %MUIE %_ETH
AND EMPLOYERS'LIABILITY YIN•
ANY PROPL E BWPARTNERIBAECUTIVE _EL EACH ACCIDENT S k„.200,000
OTcEAMMSER EXCLUDED' N N/A' -
A SaguSaguaro)).M MI
Ni 9129440615 6211126166/11/2012 E1 MSEASE EA EMPLOYES5 1,000,000sr ,
DES6RIPTION OF OPERATIONS beim.. I I E L.DISEASE-POLICY LIMIT I S 1,000,000
OESCRWTION OF OPERATIONS l LOCATIONS/VEHICLES/ACM)LOI,Atlmlivaai RemnrIs SchMNe.ow be axaphSd U MOM apace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POIACIES BE CANCELLED BEFORE
For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
C Henderson, CISRICIN t5 A H
198E4014 ACORD CORPORATION. All rights reserved.
ACORD 25(2019/01) The ACORD name and logo are registered marks of ACORD
INSO9a?x,ADn.