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23B-014 (11) 125 LOCUST ST BP-2018-1112 GIs#- COMMONWEALTH OF MASSACHUSETTS Mav:Block:23B-014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv: renovation BUILDING PERMIT Permit# BP-2018-1112 Project# JS-2018-002000 Est.Cost: $49591.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: KEITER BUILDERS 102457 Lot Size(sp.R.): 730501.20 Owner: NORTHAMPTON CITY OF BOARD OF PUBLIC WORKS Zoning: shloo)/ Applicant: KEITER BUILDERS AT. 125 LOCUST ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 n WC FLORENCEMA01062 ISSUED ON:4/26/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT NEW MEZZANINE 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 4/26/2018 0:00:00 $0.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner n 1. - -_-7 I 26 I bO l $-IIIZ i � crsioal.7 CahTnercial Ruildin Permit May 15.2000Oepa Mtarit use only City of Northampton Status of Parmit Building Department Curb CutlDn"way Permit - 212 Main Street Sever/Septic Availability Room 100 WaterNJell Availability Northampton, MA O1O60 Two Seta of Structural Pwlk phone 413-587-1240 Fax 413-587-1272 Ploysile Plain Omer Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DD/W/E/LgLIN/G/✓//�/y/C SECTION 1-SITE INFORMATION /`- 1.1 PEop&rly Adtlreae. This tectbn to be completed by office Northampton In 123 Locust M Map a 36 Lot 6/`� Unit Zone Overlay District Elm at Matrid co pretrial SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: IAD M r�.�J(1��� '1r���/✓' N F��� �� Current Malting Address 14"w" 1 M3. 5$1. W)l Signetu-e Telephone Z.2 u hod t: Keller I ars, In SJ Main Mreet I-lorence,MA UIU02 Nam(Pdog Current Marlin Address 413-58(i-86W Signature 0 — Teteptione SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by dennit a icam 1. Building 49,951.00 (a)Building Permit Fee $0 2. Electrical (b)Estimated Tolal Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) $0 5. Fire Protection 6. Total=(1 -2-3+4+5) 49,591.00 Check Number This Section For Official Use Only Building Permit Number Date slued Sgnetu Building Commiseiorrorllnspador of Buildings Date Version IT 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 ❑ Demolition❑ Repaim❑ Additions ❑ Accessory Building❑ Exterior Alteration © Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Construct new mezzanine Brief Description Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-i 0 A-2 0 A-3 0 1A El A4 ® A-5 (3 1D B Business 0 2A E Educational 0 28 F Factory 0 F-1 0 F-2 0 2C H High Hazard 0 3A 1 Institutional 0 1-1 0 1-2 0 1-3 ® 3B M Mercantile ® 4 R Residential 0 R-1 0 R-2 0 R-3 ® 5A 13 S Storage ® S-1 0 S-2 0 5B 0 U UtAay 0 Specify: M Mixed Use 0 Specify: S Speual Use 0 Specy COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group Proposed Use Group' Eusting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 8 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 1" 2n0 2.a 3m V 4m 4" Total Area(so Total Proposed New Construction(so Total Height(it) Total Height 0 P.WNer Supply(M.G.L c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: ubLc Private 0 Zone Outside Flood Zone❑ Municipal ® On site disposal system❑ Version)7 Commercial Budding Permit May 15.2000 S. NORTHAMPTON TONING Existing Proposed Required til Zoning This column to M filled In b, Budding De somem Lot Size Fronts c Setbacks Front Side L:_._R: I R. Rear Building Height Bldg,Square Foolage & Open Space Footage lint area minus bldg&pe.<d parking) #of Parkin,Spaces Fill: volume&lucari.m) A. Has a Special Permit/Variance/Finding ever been issued forion the site? NO O DONT KNOW O YES O IF YES, date Issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW Q 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 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 Buildin-Permit Mav 15.2000 SECTION 9.PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 760 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(ReglatmAt). Registration Number PAdress Expiration Dale Sgnalw Tatephone 9.2 Registered Protasalonat Engineer(s): Name Area of Responsit,A ty Address Re mnflion Number Signature Teleph. Exprapd,,Date Name Area of ResponsibOdy Address Registration Number Sgnal. TeiephoAe Ecpiration Date Name Area of Responsibnly AddreaB Regisbalion Number Slgneare Telephone Evpratim Date Name Plea of Responsibely Address Registration Number Signature Telephone Expration Data 9.0 General Contractor Keifer Builders,Inc Not Applicable m Company Name: Scott Keller Responsible In charge of ConsimcNon 36 Main M. Homnce,MA UI U62 Ayyeaa '�V`.na 413.686-8600 dtn Ka Sigrulure Telephone Version)]Commercial Building Permit Mav 15.2000 SECTION 10-STRUCTURAL PEER REVIEW 4730CMR 110.11) Independent Structural Engineenn Structural Peer Review Required Yes O No SE Hill. AUTHORQ TION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR {B��UILDIINNG PERMIT A, p ��,�( I, to �a'^,I(W�({�L/VPI�L t���an"i`A.1Ur��VS 1\V �qWF-Y� as Owner of the subject property h by au fir,Kw— 1 1La 1`-� in a y ha in all afters relative to work authorized by this building permit application. Maw Si al f Owner Date Kel B ilde ,Inc as Owner/Authorized Agent hereby declare th statements and information on the foregoing application are true and accurateto the best of my knowledge and belief. Signed under the pains antl penalties of pert ury. Scott Keiter i Pmm nn Fnd} tis 4.24.18 Sign ureof Owner/Agent Dale SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Constructlon Supervisor: Not Applicable ❑ Scott Keifer CS-162157 Nam,of Cleanse Hod License Number S I A Hatheld Street &20718 Add.p., Expiration Date 113-586-8600 halve Telephone SECTION 1a-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§2SC(S)) Workers Compensation Insurance affidavit must be completed and submitted With this application. Failure to provide this affidavit will result in Me denial of the issuance of the building Permit. Signed Affidavit Attached Yes Q No O 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: its Locust sl 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 4ID a � P %Wnt.Kel Date Y� Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2 01 7 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant In['ot'mation Please Print Le¢ibly Keiter Builders, Inc. ]`lame (BusinesslOrganization:Individuaq: Address:35 Main Street cit./Stat,/Zip,Florence, MA 01062 Phone N:413-586-8600 Are you an employer?Check the appropriate box: Type of project(required): I.Q I am a employer with 20 4. ❑ 1 am a general contractor and I employees (full and/or pan-time).' have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the anached sheet. 7. ❑i Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions q ] officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] •An.applicant that chinks box 91 must also fill out the section below showing their workers'compensation policy information. t Bomeo niers oh.submit this id idwit indicating they are doing all work and then hire notice contractors must submit a new anda%it indlcamg such. :Contractors Ihm check this bps must auaclrN 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,thev most provide their wriciscomp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name:AIM MUTUAL — Policy#or Self-ins. Lic. #:WMZ80080071392017A Expiration Date:6/1/18 125 Locust St Northampton, MA Job Site Address: Cilv'StatetZip: p 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. /do hereby y�rtify under the pains andpenalties of perjury tltal the information provided above is true and correct. (/� 4.20.18 Si nag ture President.KBI Date' Phone#: 413586-8600 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACO^ROa CERTIFICATE OF LIABILITY INSURANCE % � �6hi29i20 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 ODES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder la An ADDITIONAL INSURED,NIB Pellcy(lee)..at be elWwsad. If SUBROGATION IS WAIVED,cUbjW l0 the terms And Conditions of the policy,certain pOlklq may Mulm an enc oraemmt. A statement on this certificate time not confer rights to the certificate holder in Ileu of such endomememp. IIIOOUCrR NAMm[} Cynthia Header A CISR Rehber s Grinnell INoTIE m. a. (613)586-011. F Xp.11ulvE-,:Ie 8 North Ring Street rs'AaSS:chandezeoaPHebberaad9riR_nall.cao _NSMERfaIARPORDINGCOVERAGE XHCI Northmpten HA 01060 INSORERA:6elactive 119259 IXawEO msuRraa A.I.H. Mutual gaiter Builders, Inc. Attn: Scott Reiter NWReq O; 35 Hain Street INSURrs. _ Plereeca HA 01062 MUMR F. COVERAGES CERTIFICATENUMBERJfaster gap 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 INDICATES. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NRH RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Z TYPEOF NSU RAKE IDBP IMNY YerR ', X�V r,, as"NOT" LMra X CONLEKULIIEXERAL W&UTY DICX OC6URRENCE IS 11000,000 ��— T `� 100,000 A i cwMSMnOE pLcbR PRELrI s Ee s 9]]fi35fi] E/1/x011 HI/l0la I/{p EIP(Nry OM Cplwnl S 5,000 IVIS wLupVwARY s i,o0o,000 V.EGATE LwIr APPLIES PE✓ GERFRnL PGGREGITE 3 x.000,000 �FIXICY. jEd LOC PRCOUCiS-COLPICP AGG 8 2,000,000 OTHER ALUTTOBILE LWILRY 1� pm ELWIT S 1,000 000 A F1 AUTG 11ROOILV;Nz- r: s ALONNFD SCNEO L4F9 AUTOS X U1'OS A9103317 E/1/x011 L/3/]Ola e00RV NJURY IMr N4Eah1 S MREp AULOS KN OWNED MP OPERtt DAMAGE 1 RO$ 1A-etW a 3 5,000 I urAREuAwa (IXCVR .11OCLLWRENCf Is B OOS 000 A E6Ef3 WENI CUIMSYAOE A..rrG TE 3 pED i :FT IT o Opo axz{ss11 {/1/ao1] ¢/./Roza s NERSCOkNa.AnON I x $�jIT X Ea". ^K MNLOYERS'LWIYrY OFRr£RPLEMBER EV4VOED�GUnvE VNH N/A EL.FAG ACCOEM 8 1`00,000 B ^N n<garyb an NMZa008001119]01]a a/IL/x011 6/II/3019 EL DISEASE EA EMPLOYE 5 11000,09 0 OSCRIN.W OF OPERATION$EWa TEL m3EA3E�POLICV LIMIT 1 1000000 I]E.M1uN OPOIERAnO./LOCamTo1 VEMCLEa I...1.1 AYPMw.RI RRm,h,SefiWUM,mRY a netMtl limeh PP¢A Ia ryulrWl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence OL Insurance THE EXPIRATION TON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROWIONg. VTNOR¢Ep RFDR[SE MPINE C Hende[$on, C15A/CIN 0IM-2014ACORD CORPORATION. All rights reserved. ACORD 25(201401) The ACORD name and logo are registered marks of ACORD INSO26 m14rn Initial Construction Control Document To be submitted with the building permit application by a o Registered Design Professional for work per the 8a'edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: y.+r'I�w pm.� n A a1 Date: °/gglo( Property Address: 1ZS getvir ST Ne•np.,pm ±d fNcLn Project: Check one or both as applicable: o!tVew construction F Existing Construction Project description: A 0.—` ly FrL Iar.u2 F Gw.7/ t iL MA Registration Number: ,Jg50 Expiration date: '26/z am a registered design professional. and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [✓r Structural [ ] Mechanical ( ] Fire Protection [ ] Electrical [ ] Other for the above named project and that to the best of my knowledge, information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that 1 (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: I. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,l shall submit field/progress reports(see item 3.) together with pertinent comments, in a form acceptable to the building official. k,n Sr Upon completion of the work, I shall sub p p qt' " din'leofficial a `Final Construction Control Document'. Enter in the space to the right a"wet"ocz electronic signature and seal: Fy�rYYrf4S�i Phone number: `IlS -3H� -iyY! Email: Building Official Use Only Building Official Name: Nnn it N. Date: Version 06 11 2013