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31B-069 85 Prospect St 85 PROSPECT ST BP-2018-0130 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-069 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 Permit# BP-2018-0130 Project# JS-2018-000241 Est.Cost: $83679.00 Fee: $546.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq. ft.): 7492.32 Owner: SIMMONS RACHEL Zoning: URC(100)/ Applicant: SIMMONS RACHEL AT: 85 PROSPECT ST Applicant Address: Phone: Insurance: 85 PROSPECT ST (917) 406-4825 0 WC NORTHAMPTON MA01060 ISSUED ON:9/7/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INTERIOR REMODEL OF MASTER BEDROOM & BATHROOM 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: FeeTvpe: Date Paid: Amount: Building 9/7/2017 0:00:00 $546.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner wiwILPIcaub 0(c File#BP-2018-0130 Hdi3O O‘C-- APPLICANT/CONTACT PERSON SIMMONS RACHEL ij ADDRESS/PHONE 85 PROSPECT ST NORTHAMPTON (917)406-4825 0 ()-1 prf, d .4 PROPERTY LOCATION 85 PROSPECT ST (f°'/JSVAk . MAP 31B PARCEL 069 001 ZONE URC(100)/ tArtt THIS SECTION FOR OFFICIAL USE ONLY: r,O Pkbb PERMIT APPLICATION CHECKLIST .P431-s- ENCLOSED REQUIRED DATE 6 ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INTERIOR REMODEL OF MASTER BEDROOM&BATHROOM 1‘ I c JO a' New 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 INF9KVIATION PRESENTED: V 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 7/11/7 Signature of Building Official 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. on CStuarbtuscouuf Permit: Permit use onlyuse only -------\'''-‘k of Northampton— \ City ,„--- Building Department .. 1 S\\ 212 Main Street .. ' Room 100 Northampton, MA 01060 phone 413-5871240Fax 413-587-1272 tic Availability Sewer/Septic 11 Availability , Water/Well Structural Plans , Two.Sets of Structu Plot/Site Plans ., Other specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: Map This sectionto by be completed \ 7)--) Lot (109 8 Prospect Street N5orthampton,MA 01060 Zone oyerlay CDaisotriiacttriptoffice Elm St.District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2* 1 Owner of Record: Rachel Simmons 85 Prospect St Name(Print) Current464oMa8i2lisng Address: 9r See signed contract Telephone Signature 2.2 Authorized Aaent: Keiter Builders, Inc 35 Main St Florence, MA Namif 'lint) Current Mailing Address: ) ./ President, Kill 413-1-8 Si, ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS to be Item Estimated Cost(Dollars) Official Use Only completed by permit applicant 1. Building 70,084.00 (a)Building Permit Fee 2. Electrical . ( 4,37 Estimated Total Cost of Construction from (6) 500 •b) 3. Plumbing 9,220.00 Building Permit Fee 4. Mechanical(HVAC) 0,00 5. Fire Protection 6. Total (1 +2+3 +4+5) iii,t)/9.UU Check Number --7 / CI 1 = This Section For Official Use Only Date Building Permit Number: Issued: Signature: f Buildings Date Building Commissioner/Inspector o Section 4. ZONING Alt 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 a DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES NO Q 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 0 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 a IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alteration(s) V Roofing Or Doors rn Accessory Bldg. Demolition New Signs (C7] Decks in Siding[Cl] Other[FA Brief Description of Proposed Work: Interior remodel of master bedroom and bathroom.See plans Alteration of existing bedroom X Yes No Adding new bedroom Yes X l o 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 X 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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize Keiter Builders, Inc to ant on my hohQIf in nil matters relative to work authorized by this building permit application. 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 P;rr�Name, ie4r «' - President, Keiter Builders, Inc. 8.15.17 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8,1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder:Scott Keiter CS-102457 License Number 51A Hatfield St Northampton, MA 01060 6.20.18 Addrel Expiration Date '�r'ii President,Keiter Builders,Inc 413.586.8600 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Keiter Builders, Inc 175168 Company Name Registration Number 35 Main Street Florence, MA 01062 04/28/19 Address Expiration Date SKeiter@KeiterBuitders.com Telephone 413.586.8600 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 building permit. Signed Affidavit Attached Yes RI No 0 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 Williamsburg, MA 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: 85 Prospect St The debris will be transported by: Keiter Builders, Inc The debris will be received by: Duseau Trucking Building permit number: Name of Permit Applicant Keiter Builders, Inc 08.15.17 .Z4.0 President. Keiter Builders, Inc DateSignatureSignature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents ,Wilirnimi:l' Office of Investigations f E-711111-7 't i Congress Street,Suite 100 ,/, ••11:.simn, .. imarelt:••• i.: ‘441, ''. 54• Boston,MA 02114-2017 www.mass.govl dia 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: Type of project(required): 20 4. 0 I am a general contractor and 1 1.CI I am a employer with — 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Ci Remodeling ship and have no employees These sub-contractors have 8. Ci 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 ILO 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 13.0 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#I must also till 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 workerscomp.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:AIM Mutual Policy #or Self-ins. Lic. #:WMZ80080071392017A Expiration Date:6.11 .18 85 Prospect St City/State/Zip: Northampton, 0106( Job Site Address: 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 rtify under the pains and penalties of perjury that the information provided above is true and correct. Ye.-6 President, Keiter Builders, Inc. Signature: D08.15.17ate: Phone : 413.586.8600 # 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#: ARDS CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/29/2017 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 Webber S Grinnell PHONE WC No.Eri) (413)586-0111 FAX (A/C No):(413)586-6481 _.. 8 8 North King Street Eao4ess:chenderson@webberandgrinnell.corn INSURER(S)AFFORDING COVERAGE NAIL x Northampton MA 01060 INSURER A:Selective 1.9259___ INSURED INSURER B A.I.M. Mutual Keiter Builders, Inc. INSURERC: Attn: Scott Reiter INSURER D: 35 Main Street INSURERE: � Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER:Master Exp 2018 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 ADOL SUBR POLICY EFF POLICY EXP - - LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE 1 X I OCCUR PREMISES(Ea occurrence) $ 100,000 00 S2265567 6/1/2017 6/1/2018 MED EXP(Any one person) $ 5,000 ..—_I_, ._ _ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X i POLICY f JECT J LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: j --- ---- .$ AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT $ 1,000,000 I- (Ea accident) A ANY AUTO I BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED _...._ _.....—. _..—..,—_..._-- -----_—.._—......_ AUTOS x_ AUTOS A9105217 6/1/2017 6/1/2018 BODILY INJURY(Per accident). $ X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE AUTOS (per accident) __— $ Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE A ,_... AGGREGATE $ DED X RETENTIONS 10,000 52265567 6/1/2017 6/1/2018 $ WORKERS COMPENSATIONPER 1OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE I X ER_—, — ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? N l N/A -- - r_.—.1..._—_. B (Mandatory in NH) — WMZ80080071392017A 6/11/2017 6/11/2018 EL.DISEASE-EA EMPLOYEp $ 1,0002000 If yes,describe under -- - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /,m_,, C Henderson, CISR/CIN r� """—�' "���—� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO2R nntnnn