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31B-277 (10) 49 STATE ST BP-2019-0493 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B-277 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:REPAIR BUILDING PERMIT Permit# BP-2019-0493 Proiect# JS-2019-000800 F.st.C9st:$2000.09 F e:$100.00 PERMISSION IS HEREBY GRANTED TO: Const 1 ss: Contractor: License: use r KEITER BUILDERS 2..,;4§7 Lot i e s ft. 7579.44 Owner: COOPER'S IDAIRYLANj2 OF NTON INC nin : 100 / Applicant: KEITgR BUILDERS AT: 49 STATE ST Apglicant Address: Ph_onwe: Insuranc : 35 MAIN ST 41 586-8600 WC FLORENCEMA01062 ISSUED ON.1012412018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD EMERGENCY EGRESS GUARD RAIL 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 Finals Final: Final: Rough Frame: Gas: dire I)!enar-t:Ment Fireplacc/Chimney: Rough: Insulation,* Final; SSm ke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Ce ific to of Occu anc Si store: FeeTIRe: Date Paid: Amount: Building 10/24/2018 0:00:00 $100.00 212 Main Strcet,Phorie,(413)5$7.1240,Fax: (413)587-1272 Louis Hasbrouck—Buildhig Commissioncr File#BP-2019-0493 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORi'-XCE (413)586--3t�00 Q PROPERTY LOCATION 49 STATE ST MAP 3 1 B PARCEL 277 001 ZONE CB000V THIS SEC T:ON FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REBUILD EMERGENC ARD RAIL 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 INFORMATION PRESENTED: 1/ 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 Signatur 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. - Version 1.7 Commercial Building Permit May 15,2000 Department use only R EC E 1 V E Q City of Northampton Status of Permit: Buili ling Department Curb Cut/Driveway Permit - 2 2 Main Street Sewer/Septic Availability OCT 2 1 2.018 Room 100 WaterANell Availability orth mpton, MA 01060 Two Sets of Structural Plans phone 413-58"-1240 Fax 413-587-1272 Plot/Ste Plans DEPT.OF BUILDING INSPECTIONS Other:Specify AIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION A. Y — t j r 3 1.1 Property Address: This section to be completed by office ` `- -` _ Map r Lot A 1 7 Unit zfaS ,k� Zone Overlay District Elm St.District cB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: '�.lc�.�.g SLP�_t {� _ �--'l '"A� Telephone 4�rs j�- �t� -3i M Signature - - Ica 2.2 Authorized Agent: Keiter Builders,Inc. J.) Main Street f1orence, MA U1 U62 Name(Print) Current Mailing Address: 413-586-8600 Signature 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 $0 2. Electrical (b)Estimated Total Cost of Construction from $ 3. Plumbing Building Permit Fee FF�� 60 4. Mechanical(HVAC) If $0 5. Fire Protection 6. Total=(1 +2+3+4+5) Cup Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/inspector of Buildings Date Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTIONSERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑✓ Brief Description {e bL( -I d JAA Cb— ZBrief Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly FMI A-1 ® A-2 © A-3 Cl 1A A-4 ® A-5 1B B Business 2A E Educational 0 2B F Factory F-1 ❑❑ F-2 ❑❑ 2C H Hi h Hazard 3A ❑❑ 1 Institutional ❑❑ I-1 ❑O 1-2 ❑❑ 1-3 ❑❑ 3B M Mercantile ❑3 4 ❑❑ R Residential ❑❑ R-1 ❑❑ R-2 ® R-3 ❑❑ 5A S Storage ® S-1 ❑❑ S-2 ❑❑ 5B U Utility ❑0 Specify: M Mixed Use 93 Specify: S Special Use a_F 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) 1St St 2nd 2nd 3rd 3rd 4 t 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: F7,3ewage Disposal System: Public Private Zone Outside Flood Zone❑ ipal RZ On site disposal system[] Versionl.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 DONT 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 El 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 ess- , �.v.'�����,L 413-586-8600 President,KBI 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 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 elk;zA4A-1J Q . CC,Q11.4- �t as Owner of the subject property Keiter Builders,inc. hereby authorize to act n y behalf, inn"'all matters relative to work authorized by this building permit application. L. - \ (0 11 j � 1t Signature of Owner 13 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. Scott Keiter Printe Sign ure of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Suaervisor: Not Applicable ❑ Scott Keiter CS-102457 Name of License Holder: License Number 5IA Hattleld Street 6/20/20 Ad ss Expiration Date 413-586-8600 P . nature Telephone SECTION 13-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 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: 72 Center St 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 4;e President,Kill Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations s d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Keifer 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): I.ER I am a employer with 20 4. 0 1 am a general contractor and I 6. ® New construction employees (full and/or part-time).* have hired the sub-contractors 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. 0 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.® 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' 131R Other 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 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 72 Center St 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 rtify under the pains and penalties of perjury that the information provided above is true and correct. 10.19.18 SiX 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#: Ate 40 0 DATE(MMIDD/YWY) �, CERTIFICATE OF LIABILITY INSURANCE F05/17/2018 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: y Webber&Grinnell IAC.PHONE (413)586-0111 FAX 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 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MMIDDIYYri MMIDDIYYYYLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 RENTED CLAIMS-MADE �OCCUR PREM SES DA ToEa occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A 52265567 06/01/2018 06/01/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POUCv PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED Ix SCHEDULED A9105217 06/01/2018 06/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Medical payments s 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 52265567 06/01/2018 06/01/2019 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION X PER I X OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER B ANYETOR/PARTNER/EXECUTIVE � N/A MCC20020005382018A 06/11/2018 06/11/2019 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MECERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If ves,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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(2016/03) The ACORD name and logo are registered marks of ACORD IKEITER 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 Emergency Egress Guard Rail at 72 Center St 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" Respectfully, ott Keiter Keiter Builders, Inc.