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31B KEITER BUILDERS35 Main Street•Florence-MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilders.com Commissioner Hasbrouck 11.1.18 Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the Smith College Henshaw A Roof Project at 21 Henshaw 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" Respectfully, cott Keiter Keiter Builders, Inc. 35 Main St Florence, MA 01062 Ac(:> CERTIFICATE OF LIABILITY INSURANCE DATE(MMfOD/YYYY) 05/17/2018 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: Webber&Grinnell PNCONE No Ext; (413}586-0111 F� No: (413)586-6481 8 North King Street ADDRESS: chenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC• Northampton MA 01060 INSURER A: Selective Ins CO Of S Carolina INSURED INSURERB: A.I.M.Mutual/A.I.M. Keiter Builders,Inc. INSURER C: Attn:Scott Keiter INSURER 0: 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. LTR TYPE OF INSURANCE IND WVD POLICY NUMBER MM/DD LICY EFF MM/Da EXPLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurtencej_ $ 540,000 MED EXP(Any one person) $ 15,000 A S2265567 06/01/2018 06/01/2019 -PERSONAL&ADV INJURY $ 1'000'000 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY❑jE T F�LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ AOWNED X AS A9105217 06/01/2018 06/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE Ix AUTOS ONLY X AUTOS ONLY Per accident Medical payments S 5,000 X UMBRELLA LIAS OCCUR EACH OCCURRENCE $ 5'000'000 A EXCESS LIAR HCLAIMS-MADE S2265567 06/01/2018 06/01/2019 AGGREGATE $ 5,000,000 DEC) I X1 RETENTIONS 10'000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE X ERH. AND _ YIN N 1,000,000 B ANY CERIMEMBPROPRIETOR/PARTNER/EXECUTIVE � NIA MCC20020005382018A 06/11/2018 06!11(2019 E.L.EACH ACCIDENT $ O(Mandatory In NH) EXCLUDED? 1,000,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ If yes,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 d 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 -� - Boston,MA 02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Keiter Builders, Inc. Name (Business/OrganizatiorAndividual): 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): 1.@1 I am a with employer 20 4. ® I am a general contractor and I * have hired the sub-contractors 6• New construction employees (full and/or part-time). 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7, ® Remodeling ship and have no employees These sub-contractors have 8. ® 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 1 L® Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[R Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.® Other comp. insurance required.] *Any applicant that checks box#I 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: P Policy#or Self-ins. Lic. #: MCC20020005382018A Expiration Date:6/11/19 Job Site Address: 21 Henshaw Ave City/State/Zip: Northampton, 0106C 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. Signature._ President,KBI Date:10.26.18 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#• 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: 21 Henshaw Ave Unit A 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 0.2 .1 8 4;e President,KBI Date Signature of Permit Applicant Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural EVneering Structural Pear Review Required Yes O No • SECTION 11-OWNER AUTHOR ON-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Gary Hartwell as Owner of the subject property Keiter B ' rs,Inc. hereby authorize to act on my behalf,in all att alive to work ayy this building permit application. 10/29/18 Signature of Owner N [late Keiter Builders,Inc 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 e Sig re or qr "r/ t Date SECTION 12-CONSTRUCTION SERVICES 10.1 LlcaneW Construction Supervisor: Not Applicable 0 Scott Keiter CS-102457 Name of License tiol+der License Number ')IA Hatfield Street 6/20/20 Ad"as Expiration Date 413.586-8600 lure Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,g 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 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 13 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 Company Name: Scott Keiter Responsible In Charge of Construction 35 Main St. Florence,MA U 1062 A essA 413-586-8600 President,KBI Signature Telephone 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 DONT KNOW © YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 `.,/ NO a 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 9 acre? YES 0 NO a IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE I Interior Alterations 0 Existing Wall Signs 0 Demolition El Repairs El Additions 0 Accessory Building F] Exterior Alteration 0 Existing Ground Sign n New Signs Ll Roofing Z Change of Use❑ Other 0 Brief Description New roofing and rot repair Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 117 A-2 P A-3 1A no A-4 A-5 1B ro B Business 2A on E Educational 93 2B I on F Factory F-1 F-2 2C a H High Hazard 3A no I Institutional 1-1 93 1-2 1-3 03 3B ❑ M Mercantile 4 R Residential 97 R-1 93 R-2 93 R-3 © 5A S Storage P S-1 In S-2 fa 5B U Utility RI Specify: M Mixed Use Fol 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 I BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) i St 2nd 2nd 3`d 3rd 4 th 4 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 P Private 92 1 Zone Outside Flood 7 pal q On site disposal system❑ ,.....�,:..._,...�_�.._,,,r._. . .. �....., a �, � §yS .' b *TF`'. gg��'�• a p�4J i'�1�1'�C �Nr.s.w�'npyyV{r�. T'f � �yy ::Hj:��1at L': 'lea.. ..♦ 5 Versionl.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Parr* Building Department Curb CuWrlva+icay PenNt Saws%Se 212 Main Street pilc AvagabNlgr 3� Room 100 WeturlWell AvaGabNUy'! _ Northampton, MA 01060 TWO Sets of Struduml Plans phone 413-587-1240 Fax 413-587-1272 PlotlSits t�fatisv' QTher 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 INFORMATIO E I V E D 6A I q- 1.1 P ; This section to be completed by office 21 Henshaw Ave nit A) 1 "V 2 Map r Lot 2,M Unit no Overlay District DEPT.of 811111"IfV3PECt'—"Elm District CB District Omeo SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: The Trust s o The Smith College Name(Print) C/o FaCilit s gement, Gary Hartwell Current Mailing Address " 26 West St, Northampton, MA 01063 Signature Telephone 413-585-2441 2.2 Authors Keller Bmlders, c. j-') Main Street Vlorence,MA U1U61 Name(Print) Current Melling Address! 413-586-86W Signature 6 Telephone SECTION 3:ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only co feted by permit applicant 1. Building �j V ed (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 8 3. Plumbing / Building Permit Fee 4. Mechanical(HVAC) ( Co. 00 5.Fire Protection 6. Total=0 +2+3+4+5) !Check Number ZQ This Section For Official Use Only Building Permit Number Date Issued Signature: ;:e, f Bu Commissioner/IIs Date 21 HENSHAW AVE UNIT A BP-2019-0549 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.-Block: 3 1 B-200 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate gM:ROOF BUILDING PERMIT, Permit# BP-2019-0549 Proiect# JS-2019-000892 Est.Cost:$5000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Q jrQU: LEITER BUILDERS 102457 Lot ize(sa.ft.): 1359Q.72 Qwner.* SMITH COLLEGE OFFICE OF TREASURE Zoning:EU(100)/URC(100)/ Applicant- KEITER BUILDERS AT. 21 HENSHAW AVE UNIT A Applicant Address: Phone: Insurance: 35 MAIN ST -(413) 586-8600 0 WC FLORENCEMA01062 ISSUED ON.-111612018 0:00:00 TO PERFORM THE FOLLOWING WORK.-NEW ROOFING AND ROT REPAIR 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 Devart Ment Fireplace/Chimney; Rough: at, Insulation: Final: Smem; Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signalure: Feer e: J!ate Paid: Amoll!1t: Building 11/6/2018 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner