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31A-192 (5) 75 WASHINGTON AVE BP-2020-0057 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A- 192 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:GARAGE BUILDING PERMIT Permit# BP-2020-0057 Proiect# JS-2019-001553 Est.Cost:$80000.00 Fee: $504.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 11325.60 Owner: PITONIAK MATTHEW M&BARBARA A Zoning: URB(100)/ Applicant: KEITER BUILDERS AT: 75 WASHINGTON AVE Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON.712512019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE EXISITNG GARAGE AND BUILD NEW 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 7/25/2019 0:00:00 $504.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0057 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 Q PROPERTY LOCATION 75 WASHINGTON AVE MAP 31A PARCEL 192 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENC QUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Typeof Construction: REMOVE EXISITNG GARAGE A BUI EW 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 IN RMATION 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 //-�L-� 7 2y 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. Department use only City of Northampton Status of Permit: Building Department Cur e ay Permit A . � 212 Main Street � erl�tic A ilability Room 100 er We Avai bility Northampton, MA 01 60 Two Sets o Stru tura) Plans phone 413-587-1240 Fax 41 -587 127' � IW2e PI s Other Speci APPLICATION TO CONSTRUCT,ALTER, REPAIR REN122giON R TWO FAMILY DWELLING � tJORTHA�`� SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit 75 Washington St Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Matthew and Barbara Pitoniak 75 Washinton Name(Print) Current Mailing Address: See attached signed contract Telephone Signature 2.2 Authorized Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint) Current Mailing Address: 413-586-8600 - SiciYature 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 1`J ��p (b) Estimated Total Cost of 3 Construction from 6 11 U7 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) (0 i l 5. Fire Protection 6. Total = (1 + 2 + 3+4+ 5) U uc7 Check Number This Section For Official Use Only Date Building Permit Number: _ Issued: Signature: 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 h) Zoning This column to he filled in h) Building Department Lot Size Frontage Sethacks Front Si e L: R: L: Il:-- Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parkin Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW /--N YES Q IF YES: enter Book Page and/or Document # 13. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES 0 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 OX 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 Q NO i) 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 ❑ Accessory Bldg. [21 Demolition ❑ New Signs [01 Decks [❑] Siding [O] Other[D1 Brief Description of Proposed Work: _�(.aA �JN 1 G, "W 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 existing 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 Matthew and Barbara Pitoniak 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. See attached signed contract 6.19-19 Signature of 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. Scott Keiter Print N P,.44 6.19.19 Signa re of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Scott Kelter CS-102457 License Number _51 A Hatfield St Northampton MA 01062 6.20.20 Add re Expiration Date Pti,.k &ir 413-586-8600 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Keiter Builders, Inc. 175168 Company Name Registration Number 35 Main St Florence MA 01062 4.28.21 Address Expiration Date Skeiter@ KeiterBuilders.Com Telephone413-586-8600 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....... M No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS P ' 212 Main Street •Munici al Building --' Northampton, MA 01060 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: 75 Washington (Please print house number and street name) Is to be disposed of at: Valley Recycling (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) - . 14 k ----- 6.19.19 Agnure 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. /LG VVII LIILVIL IYGWLLID VJ III WJJ WL./L WJGLLJ Department of Industrial Accidents a Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.ntass.gov/dia Workers' Compensation lnsuranceAffidavit: 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): 1.9 1 am a employer with 20 4• ® 1 am a general contractor and employees (full and/or part-time).* have hired the sub-contractors 6. New construction I 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. 0 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 1.0 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 New gargage employees. [No workers' I ).S Other_ comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their%Norkers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all �\ork and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet shop\ing the name of the sub-contractors and state WNether or not those entities have employees. If the sub-contractors have employees. they must provide their workers' comp. policy number. 1 am an employer that is providing workers'compensation insurance./or my employees. Below is the policy and job site information. AIM Mutual Insurance Company Name: Policy # or Self-ins. Lic. #: MCC20020005382019A Expiration Date:6.11 .2020 75 Washington Florence 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 tinder 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 ,rafy�the pains and penalties ol'peiyury that the information provided above is true and correct. 6.19.19 i ahtre, __ President, Keiter Builders, Inc. Date Phone #: 413.586.8600 _ OfFcial 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#: ® DATE(MM/DD/YYYY) AC� `� CERTIFICATE OF LIABILITY INSURANCE 06/03/2019 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 ondorsement(s). PRODUCER CONTACT Cyndie Henderson CISR,CPIA NAME: Webber&Grinnell PHOC.NE . (413)586-0111 AIC No): (413)586-6481 8 North King Street ADDRIL chenderson@webberandgrinnell com INSURER(S)AFFORDING COVERAGE NAIC b Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: A.I.M.Mutual/A.I.M. Kelter Builders,Inc. INSURER C: Attm Scott Keiter INSURER D: 35 Main Street INSURER E Florence MA 01062 INSURER F COVERAGES CERTIFICATE NUMBER: Master Exp 2020 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 AUWLISUBR POLICY EFF POLICY EXP LIMITS _LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE T RENTED 500�� CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15.000 A S2265567 06/01/2019 06/01/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000,000 POLICY [:]JECT ❑LOC 2.000.000 PRODUCTS $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1.000.000 Ea accident ANY AUTO BODILY INJURY(Per person) 5 A OWNED X SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X X AUTOS ONLY Per accident AUTOS ONLY Medical payments $ 5.000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5'000'000 A EXCESS LIAB CLAIMS-MADE 52265567 06/01/2019 06/01/2020 AGGREGATE $ 5.000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE X ER H AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 1,000.000 B OFFICER/MEMBER EXCLUDED N NIA MCC20020005382019A 06/11/2019 06/1112020 (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000.000 If yes describe under E L DISEASE-POLICY LIMIT $ 1.000.000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cc>1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD care this breach of contract. Owner to follow this same notice procedure with Contractor if Owner alleges Contractor is in material breach of this Agreement. If work is stopped due to any of the above reasons (or for any other material breach of contract by Owner) for a period of 14. days, and the Owner has failed to take significant steps to cure his default, then Contractor may, without prejudicing any other remedies Contractor may have, give written notice of termination of the Agreement to Owner and demand payment for all completed work and materials ordered through the date of work stoppage, and any other reasonable loss sustained by Contractor, including Contractor's Profit and Overhead at the rate of fifteen percent (1 S%) on the balance of the incomplete work under the Agreement. Thereafter, Contractor is relieved from all other contractual duties, including all Punch List and warranty work. RIGHT TO TERMINATE CONTRACT If the work is stopped or delayed, either in whole or substantial part, for a period of thirty (30) days under an order of any court or other public authority having jurisdiction, or as a result of an act of government and due to your fault or negligence, or as a result of an act within Owner's control; or if the work shall be stopped or delayed either in whole or substantial part, for a period of thirty (30) days due to Owner's failure to make a payment on time, or make Contractor feel insecure, or if Owner should commit a material breach of any of Owner's responsibilities or obligations under this Agreement, then Contractor may, upon giving Owner seven (7) days written notice, terminate this Agreement and recover from Owner payment for all work performed; for any unpaid costs of and fees for the work; for any liability, obligations, damages, commitments, and/or claims that Contractor may have incurred or might incur in good faith in connections with this Agreement, as well as receiving payment for Contractor's attorney's and legal fees and all lost anticipated gross profits on the work not performed as of the date of the termination. NOTICE Notice will be deemed if delivered in hand or if sent by certified mail, return receipt requested, to the address listed on the front page of this Agreement. ARBITRATION THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THE CONTRACTOR HAS A DISUPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVIED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN MASS. GENERAL LAWS, C.142A. KEPTER BUILDERS, INC. (CONTRACTOR) OWNER By Scott Keiter, President Date Date Date 10 / Contractor Owner�G KEITER BUILDERS, INC. (CON'CRACTOR) OWNER lV i0 by,Scott Keiter, President Date l l Date Date ADDENDA The following have been attached to this Agreement: 1. SCOPE OF WORK 2. DRAWINGS 3. COPY OF CERTIFICATE OF LIABILITY INSURANCE 12 � Contractor Own 4 NIAP RI 1"', ..........I.. 'P VIQI� -D�V Irk A "Lot ?Ian IJ A�i I'HE FOi-lk-uV, I T ION PRLSE!" III), Af ppr(i�tc- PLASNiNG PERNUT RFQOCTRV '� Z 'OER !` a Z,ONWNk; BOARD PERNIIT RFQt"Rf'f) "*'DCR� "'al Pt77- O"ner Permits Permit f�=—EIM A of u Zoning permit do"nc-1 rejie%c a App�cAro j'i urden to c on,fA 'A ith Ali z n) c ired ptrril,ts frCm Board Or Hcaqln -ion. I)tiprt,i requ�renitsts nasi obtain all requ o . g av�h ri atitlic works and other applicable pert, itgm-in City of Northampton < Massachusetts ' r Q� DEPARTMENT OF BUILDING INSPECTIONS r , 212 Main Street • Municipal Building Northampton, MA 01060 Fee Calculator for Residential Properties Location Square Footage Amount Basement @ .20 1 ST Floor @ .50 7,,%y 3� y 2nd Floor @ .50 �....__ 7 act 2 loors, Finish Attic, (ge @ .20 Z 30 ley Deck / Porches @ .20 Total : a"�8 S�U� 7 ��&