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23C-011 (6) 597 RIVERSIDE DR BP-2020-0697 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23C-011 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2020-0697 Project# JS-2020-001191 Est.Cost: $114900.00 Fee: $270.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq. ft.): 11891.88 Owner: TRAPANI JEFFREY J&CLOVER A LEWIS Zoning: URB(100)/ Applicant. KEITER BUILDERS AT. 597 RIVERSIDE DR Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON:12/512019 0:00:00 TO PERFORM THE FOLLOWING WORK.NEW 2 STORY ADDITION 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 12/5/2019 0:00:00 $2 .00 1 Z4 , 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability �t. Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site 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 Unit 597 Riverside Drive Florence Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT --__ 2.1 Owner of Record: Jeff Trapani&Clover Lewis 597 Riverside Dr Name(Print) Current Mailing Address: —M�Y`.� See the attached signed contract Telephone Signature i 2.2 Authorized Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint) Current Mailing Address: P's-1-k413-586-8600 SigYature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1 Building ql�j (a) Building Permit Fee 2. Electrical �l /�' (b) Estimated Total Cost of i— Construction from 6 3. Plumbing \ cfz Building Permit Fee 4. Mechanical(HVAC) a 5. Fire Protection 0 6. Total= (1 +2 + 3 +4 +5) wA 05 i Check Number 1 OCL This Section For Official Use Only Building Permit Number: _�o_—r,� Date Issued' Signature: &/ l 9 Building Commissioner/Inspector of Buildings Date BGrant @ KeiterBuilders.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition © Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding [01 Other[01 Brief Description of Proposedr�ae• Work GL/t GC -� Gr(vr 2 vt r� SP�c ce d- 1 ct �- 8�Q Alteration of existing bedroom Yes x No Adding new bedroom Yes 42 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, Jeff Trapani&Clover Lewis 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 the attached signed contract 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 z P, , B� 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 Addre Expiration Date P�,G t �•— 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....... ® No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS �, k - p 212 Main Street •Municipal Building Northampton, MA 01060 ri�'�V '�� 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: 597 Riverside Dr (Please print house number and street name) Is to be disposed of at: Valley Recyclinq (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) 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. The Commonwealth of Massachusetts Department of Industrial Accidents f; 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 Ci /State/Zi Phone #; Florence, MA 01062 413.586.8600 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 am a employer with 25 4. 0 1 am a general contractor and 1 6. ® New construction employees (full and/or part-tirne).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have nb employees These sub-contractors have 8. 0 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 Roofre airs insurance required.] t c. 152, §1(4),and we have no 9ebuild porch employees. [No workers' 13.® Other comp. insurance required.] *Any applicant that checks box#1 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. 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. #: MCC20020005382.019A Expiration Date: 6.11 .2020 597 Riverside Dr Florence, MA 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 rafy�the pains and penalties of perjury that the information provided above is true and correct. Si nature. President, Keiter Builders, Inc. Dat e:10.23.19 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#: — A��® DATE(MM/DDIYYYY) `" 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 endorsement(s). PRODUCER CONTACT Cyndie Henderson CISR,CPIA NAME: Webber&Grinnell PHONE (413)586-0111 FAX (413)586.6481 ExtI, AIC No 8 North King Street E-MAIILchenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: 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 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. NSR ADDL5UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MMIDD/YYW X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE T AMA ET RENTED. ENTED 500,000 CLAIMS-MADE �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 RPOLICY ❑PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER. COMAUTOMOBILE LIABILITY Ea a8ciu.D SINGLE LIMIT $ 1,000,000 IANY AUTO BODILY INJURY(Per person) $ OWNEDX SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOSONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Medical payments $ 5,000 X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 52265567 06/01/2019 06/01/2020 AGGREGATE $ 5'000'000 DED I X RETENTION$ 10,000 �/ X $ WORKERS COMPENSATION X PER TE /� ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.I.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? � NIA MCC20020005382019A 06/11/2019 06/11/2020 E.I. DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) . 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 Evidence of Insurance 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 City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building b Northampton, MA 01060S �? Ty "4.1:7% Fee Calculator for Residential Pro erg rties Location : l r Square Footage Amount Basement @ .20 1 ST Floor @ .50 I S 2nd Floor @ .50 a 5-D 1/2 Floors, Finish Attic, Garage @ .20 Deck / Porches @ .20 — - Total : 02