45-010 (7) 127 COMBS RD BP-2018-1305
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map'Block:45-010 CITY OF NORTHAMPTON
Lot.-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category window replaced BUILDING PERMIT
Permit# BP-2018-1305
Project# JS-2018-002325
Est Cost,$7500.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.const. Class: Contractor: License:
Use Group: KEITER BUILDERS 102457
Lot Size(sp.ft.): 14226696.00 Owner: MASSACHUSETTS AUDUBON SOCIETY INC
zoning: Applicant: KEITER BUILDERS
AT. 127 COMBS RD
AoplicantAddress: Phone: Insurance:
35 MAIN ST (413) 586-8600 n WC
FLORENCEMA01062 ISSUED ON.-
TO
N.TO PERFORM THE FOLLOWING WORK:5 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 Department Fireplace/Chimney:
Rough: OOI• 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:
FeeTvoe: Date Paid: Amount:
Building 6/11/20180:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
a13
edc] Version l]C'nmmrCial Buildin Permit Mav 15.2(00)it Department use only
City of Northampton Statim of Perms[lJ Building Department Curb Cut/orlueway Permit
a 212 Main Street Se ver(Septic Availability
Room 100 WeterAMell Availability
Northampton, MA 01060 TWo Soft of Structural Plana
phone 413-587-1240 Fax 413-587-1272 PlaUSite 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 6p-
1
v'
1.1 Pro e�Addres : This"clean to be completed by office
t2 07 mC les Rd-A1ass Audubon Farm House � /(
Map •-f5 Lot Oto Unit
Zone Overlay District
Dm SL Dlmdct CB matrlel
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Poem,:
m a9oxtC4l�t'x�5 pu�lu��✓+ Scuz+\I I"< JCP Scam.,+ Qct, l„r,r-6, )4q Ci943
Nam(NN){j GKW�'�' Rt`Y " +.'regS.1uPL/C Cunmt Malting" ---
:
alatd
Signature t Telephone
2.2 Authorized
Ketter Builders, Inc. A Main Street Florence,MA U 1062
Name(Punt Current Maign Address'.
413 , -x600
Sgnahve Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offipal Use Only
completed bpermit applicant
1. Building -T sw (a)Building Permit Fee $0
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Pamir:Fee
4. Mechanical(HVAC) "� I l�D $0
5.Fire Protection
6. Total=(1 +2+3+4+5) 1 Check Number L) *7
This Section For ONlcis]Use Only
Building Permit Number Date
Issued
Sig na:
Buildire 10 «a1 ngn Date
Version[.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED,SPACE'
Interior Alterations ❑ Existing Wall.Signs ❑ Demolltlon0 Repairs❑ Additions O Accessary Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs n Roofing[-] Charge.ot Use❑ Other Z✓
Brief Description Five replacement windows
Of Proposed Work:
SECTION 5•.USE GROUP AND CONSTRUCTION TYPE
USE GROUP Check as applicable CONSTRUCTION TYPE
A Assembly ® A-1 A-2 ® A-3CIJ3 'IA Q
A-4 A-5 ® 1B
B Business ® 2A �
E Educational ® 28 ' L�
F Factory ® F-1 ® F-2 n 2C
H HIIII,Hazard ® 3A 9-3
1 Institutional im 1-1 1-2 ® 1.3 ® 3B 12
M Mercantile M 4
R'. Residential 9 R-1 ® R-2 rj R-3 ® SA
S Storage 9 S-1 71 8-2 ® 5B
U Utility ® Spedfy;
M Mixed Use ® Specify:
S Special Use ® Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):'.
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sl
1:1 1'r
2re 2ra
3,d 3.d
Gin
Total Area(sq Total Proposed New Construction(sl
Total Height(it).
Total Height It
].Weter Supply(M.G.L.a 40,§54) ].1 Flood Zone Information: ].3 Sewage Disposal System:
Public f Private Zone Outside Flood Zone[] Municipal g On site c urposal system❑
Versionl 7 Commercial Building Permit May 15,2000
8 NORTHAMPTON•ZONING i.
Existing Proposed Required by Zoning
n e odomvm be filled m by
Building Deyap,nem
rut Size
Frontage
Setbacks Front
Side L R.— I,:_ R�
Rear
Building Height
Bldg.Square Footage ^k
Open Space Footage %
(Isx area minas bldg&paved
Min )
M of Parking$ aces
RIi:
vMun,e&n.ocariw).
A. Has a Special.Permit/Variance/Finding ever been issued for/on the site?
NO O DON7 KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does thesite contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES,has a permit beefrror need to be obtained from the.Conservation Commission?
Needs to be obtained O Obtained O ,.Date Issued:
C. Do any signs exist an the property? YES O NO O
IF YES, describe size, type and location:
D. Are thereany proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. WII the construction activity disturb(clearing,grading,excavatlon,or filling)over t acre or is it part of a common plan
that will disturb over 1 acre? YESO NO O
IF YES,then a Northampton Storm Water Management Permit tram the DPW Is.required.
Va.umt.7 Commercial Building Permit May 15,2DBO
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 93
Name(Re tlsiree'
Respun tion Number
Address
EV"tiol Date
Signelure Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
More. Registration Number
Signahae Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Dale
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiation Date
Name Area of Responaibirty
Addreps Regislratidn Number
Signature Teiephone Explradon Dale _
9.3General Contractor
Keifer Builders,Inc
Not Applicable.[0
Company Name:
Scott Keifer
Responsible In Chage of Construction
35 Matn SI.Florence,MA 0 106
A ess
ala-sxe-aboo
ere��e�ar ext
Signature Telephone
Version 1.7 Commercial Building Permit Nay 15.2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION II-OWNER AUTHORQATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i
I. "v//* v R SBS I rrn 5,r,Lr✓ �-i .as Owner of the subject properly
herebyauthorize ke '- C4- 4J Lt 1�Cl¢4"5 LIC, to
a:71 ybe If,in!7tte� ativs to work authodxed by this building permit application.
/1 6 �!c
Sgrature of r Date
Keifer Builders,Inc
I, ,as OymedAuthoraed
Agent hereby declare that the statements and information on the foregoing application are"a and accurate,to the best of my knowledge
and belief.
Signed under Me pains and penalties of parlury.
Scott Keiter
Prim e �/
624,18
Stgriliture of OanenAgenl Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Scott Keiter ('S-102457
Name of U mse Holder
License Number
I A Hatneld Street 6/20/18
A ss 413-586-8601) Expiration Date
ftnawro Tebphore
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Mi c.152,§2SC(8))
Wowers Compensation Insurance affidavit must be completed and submided with this application. Failure to provide this affidavit will result
in the denial of the issuance of Me building permit.
signed Affidavit Attached Yes Q No
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: Ili comb:ad
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
ELL, i,}!it PreniJenp Kai
Date Signature of Permit Applicant
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
ADDlicaot Information Please:Print Legibly
Naltltl tansiness/Organizatiun/Individual): Keiter Builders, Inc.
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):
LE I am a employer with 20 4. ® 1 am a general contractor and 1 6.. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors.
2.® I am sole proprietor or partner- listed an the attached sheet. 7. ® Remodeling
bcontractors have
ship and have no employees These su8. ®Demolition
working forme in any capacity. employees and have:workers' 9 ®Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We area corporation and.its 10.0 Electrical repairs or additions.
3.® 1 ran a homeowner doingall work officers have exercised.their 11.®Plumbing repairs or additions
myself. [No workers' comp.: right of exemption per MGL 12 ® Roof r���opp� irs
insurance required.] t c. 152, §I(4), and Nye have no W IndowS
employees. [No workers' 13.1 Other
comp. insurance required.]
"My applicauthat cheeks.box•#I mustalso fill aurtlu section belpw shntiin@ rheic smrkeis'cbmpcnselion policy mbormmion.
s
Itionea,mors,ho submit this andavitindinning lhcy are doing all,vml:and then hire oubiaceontractors must submit anew affidavit indicating such.
IConnaetors that Bieck this box most attached an additional shed shmving the name oftha sub-contractors and state whether or not those entities have
employees. If the sub-contraaors have employees.they most providetheir workers'comp,policy murmur
I an,rat employer Umt is providing workers'compensation iasarancefor my employees. Below is the policy and job site
information.
Insurance.Company Name:
AIM MUTUAL
Policy#or Self-ins.Lic_.# MCC20020005382018A: Expiration Date:6/11119_
127 Combs Rd Northampton, 0106(
Job Site Address: City/Stave/Lip:
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 theimposition ofcriminal penalties ofa
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of aSTOP WORK ORDER and afire
of up to$250.00a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
7 da herebyify ander the pants and penalties of perjury that the information provided above dr true and correct. —
/j� 5.28.18
Simature `– President,KB1 Date:
Phone e: 413586-8600
Official use only. Do not write in this area,to be completed by city or lown official.
City or Town: PerminLicence#
Issuing Authority.(cirde one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact.Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.HOLDER.THIS
CERTIFICATE DOES NOTAFFIRMATNELY 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: It the certificate hoi I.an ADDITIONAL INSURED,the ANEc Ues),must have ADDITIONAL INSURED propisWm or M eMdmcd.
If SUBROGATION IS WANED,aGbI to the terms and condMons M then POIDY,canal"policies May require an eMohemeM. A shtemcnt on
this ceHlTMandoes not center rights to the certificate holder In[hill of each endomamennel.
PRODUCER Cymtia Henderson CISR Ell.
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COVERAGES CERTIFICATE NUMBER[ Mosler E%p Incur REVISION NUMBER:
THIS 16 TO CERTIFY THAT THE PCI-CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO)HE INSURED NAMED A&Gi FOR THE PCUCY PERI00
INDICATED. NOTNTHSTANDING ANY REOUMEMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS.
CERTIFICATE MAY REISSUED OR MAY PERTAIN,WE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
E%CLUSIONSAM.CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TVEOFMSURANCE MF-C' MMNWYW tlMNp/IYYY URITS
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'LPGGREGAE LIMITAPRIES PER: 2,000,008
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CERTIFICATE HOLDER CANCELLATION
SHOULD My OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E%PIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTBIGIV ED RERE6ENMT WE
0 10881 ACORD CORPORATION. AG riphh reserved.
ACORD 25(2016013) Ties ADDED name and logo are registered marks of ADDED