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31B-196
14 HENSHAW AVE BP-2020-0498 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block:31 B- 196 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2020-0498 Proiect# JS-2020-000853 Est.Cost: $75000.00 Fee: $487.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 7143.84 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(100)/URC(100)/ Applicant: KEITER BUILDERS AT. 14 HENSHAW AVE Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON.1011812019 0:00.00 TO PERFORM THE FOLLOWING WORK.-ROOFING AND SIDING 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 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: FeeTvpe: Date Paid: Amount: Building 10/18/2019 0:00:00 $487.50 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner CC P./k <2, Department use only -IV TJ rim City of NorthamptonRE Status of Permit: Building Department CES ` t/Driveway Permit 212 Main Street ` /Septi¢Availability Room 100 OCT Wate/Well/Availability Northampton, MA 0 60 TFwo ets Structural Plans phone 413-587-1240 Fax 4TISr- 72 Plo Site sans No�rNan r� rn�cpE er Sp cify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE_ C H A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION p 1.1 Property Address. This section to be completed by office Map �� Lot Unit 12/14 Henshaw Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: The Trustees of The Smith College c/o Facilities Management, Gary Hartwell 126 West St., Northampton, MA Name(Pri t) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint) Current Mailing Address: PNS,e_k esz 413-586-8600 Sig ature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars)to be Official Use Only completed by permit applicant 1 Building -� (a) Buildinq Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee . 4. Mechanical (HVAC) � 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) OJa Check Number l0 This Section For Official Use Only Date Building Permit Number: Issued: Signature: A., D 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 170 (I.)t area minus bldg&paved arkin tl 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 Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW Q YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO OX DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aplicp able) New House ❑ Addition ❑ Replacement Windows Alteration(s) © Roofing Or Doors 13 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other[C7J Brief Description of Proposed Work: Roofing & Siding Rot Repair 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, Gary Hartwell, Facilities Management as Owner of the subject property hereby authorize to act on my behalf, 'n all matters relative to work authorized by this building permit application. 10/18/19 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 Kp'ter Print N PNt, �<< \ kI`l Signa re 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 AddreExpiration Date P�f 413-586-8600 Signature Telephone 9, Realstered 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....... IN No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building y3j hb 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: 12/14 Henshaw (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: USA Waste (Company Name and Address) 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 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 LeLlibly 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 25 4. ® I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors �' New construction 2.® 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' q ® Building addition [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 10.® Electrical repairs or additions 3.® 1 am a homeowner doing all vtiork officers have exercised their 1 1.® 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.® 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:__ Policy# or Self-ins. Lic. #: MCC20020005382019A Expiration Date: 6.11 .2020 12/14 Henshaw 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 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 herebyrf rtify under the pains and penalties of perjury that the information provided above is true and correct. 10.18.19 Signature: President, keiter Builders, Inc. Dat e: 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 Invectol' 6.Other Contact Person: Phone#: AcoR" CERTIFICATE OF LIABILITY INSURANCE DATE 103/2019 Y) �/ 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 endorsement(s). PRODUCER CONTACT Cyndie Henderson CISR,CPIA _NAMEWebber&Grinnell PHOWC.NE (413)586-0111 qIC No): (413)586-6481 8 North King Street ADDRIL chenderson@webberandgrinnell.com INSURERS)AFFORDING COVERAGE NAIC p Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: A.I.M.Mutual/A.I.M. Keller Builders,Inc. INSURER C Attn:Scott Keiter INSURER D: 35 Main Street INSURER E Florence MA 01062 1 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. ADDLSUBR POLICY EFF POLICY EXP ITR TYPE OF INSURANCE I D WVD POLICY NUMBER MMIDD/YYY MMIDD/YYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2019 06/01/2020 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 PRO 2,000,000 POLICY El LOC OTHER AUTOMOBILE LIABILITY Eaa accident SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per Person) $ A OWNED X SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE X HIRED X NON-OWNED $ AUTOS ONLY AUTOS ONLY Per accident Medical payments $ 5,000 X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS�L/IAB CLAIMS-MADE 52265567 06/01/2019 06/01/2020 AGGREGATE $ 5,000,000 DED u RETENTION$ 10,000 $ WORKERS COMPENSATION PER �/ ER X STATUTE /� ER AND EMPLOYERS'LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NJ NIA MCC20020005382019A 06/11/2019 06111/2020 E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? 1,000,000 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ If yes describe under1,000,000 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. Evidence of Insurance AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD