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17A-127 (15) 305 BRIDGE RD BP-2019-0733 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Block: 17A- 127 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate-M:REPAIR BUILDING PERMIT Permit# BP-2019-0733 Project# JS-2019-001206 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sa. ft.): 22999.68 Owner: WANCZYK RICHARD J&JUDITH M Zoning: URA(100)/ Applicant. KEITER BUILDERS AT. 305 BRIDGE RD Applicant Address: Phone: Insurance: 35 MAIN ST (413)586-8600 (L WC FLORENCEMA01062 ISSUED ON.12/20/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIRS TO HOME DUE TO CAR CRASH 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 12/20/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0733 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 Q PROPERTY LOCATION 305 BRIDGE RD MAP 17A PARCEL 127 001 ZONE URA(100)/ 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: REPAIRS TO HOME DUE TO CAR CRASH 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: 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 2-20-/G Sig4ture 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. Department use only City of Northampton Status of errnit ;a Building Departm nt Curb Cut/ rive%Aay Permit 212 Main Stree DEC 2 0 r/Se tic A% ilability Room 100 Water/MW I Avai ability Northampton, MA 069EPT OF BUILDING f Str tural Plans phone 413-587-1240 Fax - �L(11r�IMPTON,Pfr> ft e Plans Other Specify_, APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map_ Lot ,�,�_7 Unit' 305 Bridge Rd Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Richard Wanczyk 305 Bridge Rd Name(Print) Current Mailing Address: V—p— C1Ay'_'A— Telephone Signature 2.2 Authorized Aaent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint)) Current Mailing Address: E%�1,. P, 413-586-8600 SigrIature 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 2. Electrical (/tom (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee i_1W 4. Mechanical(HVAC) 5. Fire Protection 6. Total= 0 +2 +3+4+5) Check Number 7<1 This Section For Official Use Only Building Permit Number: Date Issued: Signature: /Z- ZO - !6 Building Commissioner/Inspector of Buildings Date BGrant @ KeiterBuilders.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 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 Q DON'T KNOW ) YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW k�) YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO G DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO t�X IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES l NO Ii Xt 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[©] Brief Work escriptiofpo i , /J Alteration of existing bedroom Yes x No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes x —No Plans Attached Roll -Sheet 6a. If New house and or addition to existina housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Richard Wanczyk as Owner of the subject property hereby authorize Keiter Builders Inc to act on my behalf, in all matters relative to work authorized by this building permit application. sceL 12 03.18 Signatur o Owner Date I, Keiter Builders Inc 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. Scoff Keiter Print N PN , iz. 12.03.18 Signre of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Scott Keiter CS-102457 License Number 51 A Hatfield St Northampton, MA 01062 6.20.20 Addre Expiration Date L-J E wiz 413-586-8600 Signature Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ Keiter Builders, Inc. 175168 Company Name Registration Number 35 Main St Florence MA 01062 4.28.19 Address Expiration Date Skeiter@KeiterBuilders.Com Telephone 413-586-8600 SECTION 10-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 Massachusetts 'r DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 �h, Debris 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. The debris from construction work being performed at: 305 Bridge Rd (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Duseau Trucking (Company Name and Address) &;V R -4 � IA-02: 12.3.18 gnature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents T v Office of Investigations 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 Keiter 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): 1.F I am a employer with 20 4. ® 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ® New construction 2.® l am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, ® Demolition working for me in any capacity. employees and have workers' 9. 0 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] + c. 152, §1(4), and we have no HepairS employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 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: MCC20020005382018A 6.11 .2019 Policy#or Self-ins. Lic. #: 2,� Q2, ,��,,a Expiration Date: Job Site Address: e0v �`�� r✓r"— city/State/Zip: Easthampton, MA 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. 1 do hereby1f rtify�the pains and penalties of perjury that the information provided above is true and correct. 12.03.18 Signature: President, Keiter Builders, Inc. _ Date: 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#: ACo® CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYWY) I6. / 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(ies)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 NAME: Cynthia Henderson CISR Elite Webber&Grinnell PHONE (413)586-0111 FA ,No): (413)586-6481 8 North King Street E-MAIL chenderson@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: 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 AVUL bUtSH1 POIJCY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVQ POLICY NUMBER MMIDDIYYW MMIDDIYYYYLIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE ❑X OCCUR PREM SESOEa oaur ante $ 500,000 MED EXP(Any one person) $ 15,000 A S2265567 06/01/2016 06/01/2019 PERSONAL BADV INJURY $ 1,000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PEC LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED A9105217 06/01/2018 06/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Medical payments s 5,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 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 PERO $ WORKERS COMPENSATION X STATUTE X ERT ANDEMPLOYERS'LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE [_N] NIA MCC20020006382018A 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 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 n ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD it KEITER BUILDERS, INC. OWNER `f /.... /. y,� ..iJ,L ! ,✓,. fir, By,Scott keiter, President Date Date j' Date NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THF..: AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. ]'HE RIGHT TO INITIATE ALTERNATIVE DISPUTE RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THIS AGREEMENT. MISCELLANEOUS: This agreement is a Massachusetts contract, contains the entire agreement between us, any representations or warranties not expressly contained in it are not a part of the Agreement, and it is binding upon our heirs, executors, successors and assigns. This Agreement may be modified only by an instrument in writing signed by both of us. This agreement is subject to and is intended to comply with the provisions of Chapter 142A of the Massachusetts General Laws and its corresponding regulations. Owner understands and acknowledges that Keiter Builders, Inc. may use any photos taken during the course of work for promotional purposes. This may include, but is not limited to, the following: Website, newspapers, Journals. magazines, posters, and flyers. RIGHT TO CANCEL CONTRACT: YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO BY FORWARDING YOUR INTENT TO CANCEL IN WRITING BY ORDINARY MAIL POSTED. BY "1 FIA_-GRAM SENT OR BY DELIVERY, NOT' LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. By signing this Agreement. you acknowledge that you have received a complete and original signed copy ofthe entire Agreement and attached Exhibits. Keiter Builders, Inc. may not start work until after this Agreement has been signed. 5 DO AVT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS IS A LEGALLY SIA"DING AGREEMENT. IF THERE ARE ANY PROVISIONS WHICH YOU DO NOT UNDERSTAND, YOU SHOULD CONSULT WITH AN ATTORNEY BEFORE SIGNING. KI,.ITER BUILDERS, INC. OWNER 6y, Scott Keiter, President Date A Date Date 6