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24B-086 26 CARLON DR BP-2019-0494 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24B-086 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:Door Replacement BUILDING PERMIT Permit# BP-2019-0494 Project# JS-2019-000430 Est.Cost: $1000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: KEITER BUILDERS 102457 Lot Size(sq-ft.): 87163.56 Owner: CITY OF NORTHAMPTON NEW FIRE STATION Zoning:HBO Applicant: KEITER BUILDERS AT. 26 CARLON DR Applicant Address: Phone: Insurance: 35 MAIN ST (413)586-8600 0 WC FLORENCEMA01062 ,ISSUED ON.1012412018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE AND INSTALL NEW DOOR AND FRAME IN BACK SERVICE ENTRANCE 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: mom : 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 10/24/2018 0:00:00 $0.00 212 Main Street,Phone(413)5871240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0494 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 Q PROPERTY LOCATION 26 CARLON DR MAP 24B PARCEL 086 001 ZONE HB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REMOVE AND INSTALL NEW OR AND FRAME IN BACK SERVICE ENTRANCE New Construction Non Structural interior renovations Addition to Existing Accessoty 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 INF9RMATION 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 ,� f to hs l8 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. ECEwED Version).7 Commercial Building Permit May 15,2000 Department use only 21 2018 Q of Northampton Status of Permit: OCT Buil ing Department Curb Cut/Driveway Permit 2 Main Street Sop Rveilabifity DEPT.of g L0041G tNSPEC'rttN� Oom 100 1N "'a AvIsk tlillty' PTON.MA01� NOATt+AM ampton, MA 01060 Two ; f Structure Plane ttrt T, phone 41377- -587-1240 Fax 413-587-1272 PIS Pku+s ? t k . a .Y• . C'ldtar 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 ProR2rtY Address: Thissectionto be completed by office 26 Carlton Ur- Northampton lire Ueptartment Map �{ 6 Lot L/ U Unit ` Zone Overlay District Elm St District CO District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �r� � Akemhtolzt— Name(Print) Current Mailing Address: 7rrci �'en-fro�(strvrtc� Lf D h'jarn. � DUI�t° 3 Signature Telephone AY13 30 2.2 Author KerteHui ers, nc J.) Main street Morence,MA U106'2 Name(Print) Cu 413--a5i8MAdd 86s, Signature Telephone SECTION-3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to beOfficial Use Only completed by permit applicant,"' 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) J I $0 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissionerlinspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 9L0(9b 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ RepaimeRPAdditions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roof��ing Change of Use F] Other❑✓ Brief Description �, .4'kag- CA&& y.SVJ--//. V_k, GQxC r k 6&A- - Of Proposed Work: 10„ „t 'St.o'Ce SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 M A-2 ® A-3 ® 1A A-4 ® A-5 ® 1B 03 B Business 0 2A 93 E Educational 0 2B 93 F Factory 93 F-1 0 F-2 ❑❑ 2C H Hi h Hazard 0 3A Institutional M 1-1 R3 1-2 M 1-3 a 3B M Mercantile 0 4 M R Residential M R-1 M R-2 ® R-3 M 5A M S Storage M S-1 M S-2 ❑❑ 5B U Utility ❑� Specify: M Mixed Use © Specify: S Special Use M 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) 1 St 1 St 2nd 2nd 3rd 3rd 4 4th th 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: Public R Private © I Zone Outside Flood Zone❑ Municipal EM On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 O DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O 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 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 1.7 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 11 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 Responsibility 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 St. Florence,MA 01062 A ess1 , .G�.�c;;....���, President,KBI 413-586-8600 Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 DA-V I A Iv, Dl--r-lir teC11/It-C-3, as Owner of the subject property Keiter Builders,Inc. )ibehfV1 rize to amatters relative to work authorized by this building permit application. n u f owne Date Ket er Builder I I, 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 �� PP.f,.b SignWlure of owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 12.1 Licensed Construction Supervisor: Not Applicable ❑ Scott Keiter CS-102457 Nams of Ucense Holder License Number ')I A Hatheld Street 6/20/20 Adorrs 413-586-86MExpiration Date nature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(8)) 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 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: 26 Carlton Dr 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 10.19.18 i�u5 President,1031 Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents f Office of Investigations d I Congress Street, Suite 100 <` Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A20icant Information Please Print Legibli Name (Business/Organization/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): I.ER I am a employer with 20 4. ® I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ® 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 3.® 1 am a homeowner doing all 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.] t c. 152, §1(4),and we have no employees. [No workers' 13.99 Other comp. insurance required.] *Any applicant that checks box#1 must also fill 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 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. AIM MUTUAL Insurance Company Name: Policy# or Self-ins. Lic. #:MCC20020005382018A Expiration Date:6/11/19 26 Carlton Dr Northampton, 0106( 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 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 qprnfy under the pains and penalties of perjury that the information provided above is true and correct. 10.19.18 Si nature: President, KBI Date: Phone #: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACS 05/1717CERTIFICATE OF LIABILITY INSURANCE DATE /I2018 ) 018 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(les)must have ADDITIONAL INSURED provisions or 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 Elite NAME: Webber&Grinnell PHONE (413)586-0111 n� No: (413)586-6481 8 North King Street E-MAIL chenderson@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: Selective Ins Co of S Carolina INSURED INSURER B: A.I.M.Mutual/A.I.M. Keiter Builders,Inc. INSURER C: Attn:Scott Keiter INSURER D: 35 Main Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2019 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 CONTRACTOR 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. ILTEXP R TYPE OF INSURANCE POLICY NUMBER MMIDM'YY MM CYEFF IDYIYYW LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TRENTED 500,000 CLAIMS-MADE FX-]OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2018 06/01/2019 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑JEo LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER. $ AUTOMOBILE LIABILITY COa MBINED ccidentSINGLE LIMIT E $ 1,000,000 a ANY AUTO BODILY INJURY(Per person) $ A OWNED 1xx SCHEDULED A9105217 06/01/2018 06/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS XHIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE s 5,000,000 A EXCESS LIAB CLAIMS-MADE S2265567 06/01/2018 06/01/2019 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE X ORTH- AND EMPLOYERS LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA MCC20020005382018A 06/11/2018 06/11/2019 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD KEITER BUILDERS35 Main Street•Florence•MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilders.com Commissioner Hasbrouck 10.19.18 Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the Door Project at 27 Carlton Ave 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" Respe ully, c tt Keiter eiter Builders, Inc.