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10-016 (6) 218 AUDUBON RD BP-2020-0805 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10-016 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-2020-0805 Proiect# JS-2020-001391 Est.Cost: $87000.00 Fee:$566.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq. ft.): 326133.72 Owner. BORAWSKI KATHLEEN Zoning: RR000)/WSP(100)/WP(26)/ Applicant: KEITER BUILDERS AT. 218 AUDUBON RD Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 0 WC FLORENCEMA01062 ISSUED ON.]/]612020 0:00.00 TO PERFORM THE FOLLOWING WORK:BUILD NEW 3 SEASON PORCH 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 1/16/2020 0:00:00 $566.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner o�� pry File#BP-2020-0805 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600 Q PROPERTY LOCATION 218 AUDUBON RD MAP 10 PARCEL 016 001 ZONE RR000)/WSP(100)/WP(26)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIS ENCLOS REQU ED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid TypeofConstruction: BUILD NEW 3 SEASON PORCH ADDI ON poO- 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 INFO ATION 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 ALk— � , 3&t� V)6/ao Signpre of Building Official Pb 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 Northarppto f Per it: Building Deparme IAN 3 Curb ut/Dri eway Permit 212 Main Sreet �Q Oewe Septi Availability Room 100 Wate/Well vailability Northampton, A ODIFr. ets o Structural Plans p �_ uitDINJ tNSP phone 413-587-1240 Fax13=5� �.r,�q n �P9te PI ns e ify 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 218 Audubon Rd Leeds Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kathy Borawski 218 Audutxm Rd 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: QKs, &ems 413-586-8600 SigHature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building �i , (a) Building Permit Fee �S�G 2. Electrical (b) Estimated Total Cost of 'l' xv Construction from 6 G• 3. Plumbing SID Building Permit Fee L 4. Mechanical(HVAC) S�6 5. Fire Protection 6. Total =0 +2 + 3 +4+5) 000 Check Number a This Section For Official Use Only P_ U , Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date BGrant @ KeiterBuilders.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all ap lip cable) New House ❑ Addition ✓❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [lam] Other[O] Brief Description of Proposed Work: Build new 3-seasons porch addition 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 X 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 1, Kathy Borawski 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 01.14.2020 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 PN , az. 01.14.2020 Sign re of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su en rvisor: 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 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 4.28.21 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 x x 212 Main Street •Municipal Building r Northampton, MA 01060 A,-,)\ 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: 218 Audubon Rd (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) 01.14.2020 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 I 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 Name (Business/Organization/Individual): Keiter Builders, Inc 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. ® 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ® New construction 2.® 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ® 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 11.® Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.� Other Addition employees. [No workers' 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 mV 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_ 30 Cherry Street Northampton 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 rtify�the pains and penalties of perjury that the information provided above is true and correct. 01 .14.2020 Sin tore: 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 G.Other Contact Person: Phone#: AC V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `.►� 06103/2019 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 C ndie Henderson CISR,CPIA NAME: y Webber 8 Grinnell PHONE (413)586-0111FAX (413)586-6481 A/C No): 8 North King Street E-MAIL chenderson(8webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSUREDINSURER B: A.I.M.Mutual/A.I.M. Kelter Builders,Inc. INSURER C: Attn:Scoff 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MMIDDIYYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE T RENTED 500,000 PREMISES Ea occurrence $ MED EXP(Any onePerson) $ 15,000 A S2265567 06/01/2019 06/01/2020 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2.000,000 POLICY EI E T F1 LOC PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 a accident ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acci en Medical payments s 5,000 LA X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5'000'000 EXCESS LIAB HCLAIMS-MADE S2265567 06/01/2019 06/01/2020 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 �/ �/ TH- $ WORKERS COMPENSATION X PEAT TE /� OR AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1.000,000 B OFFICER/MEMBEREXCLUDED9 N/A MCC20020005382019A 06111/2019 06!11/2020 (Mandatory in NH) E .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/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(2016103) The ACORD name and logo are registered marks of ACORD 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. KE BUI DERS, INC. ( NTRACTOR) OWNER B , c tt titer, Presu 'Ili Uatr -44Date Date NOTICE THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE 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. THE RIGHT TO INITIATE ALTERNATIVE DISPUTE RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THIS AGREEMENT. DISPUTE RESOLUTION AND ATTORNEY'S FEES Any controversy or claim arising out of or related to this Agreement involving an amount less than $5,000 (or the maximum limit of the Small Claims court) must be heard in the Small Claims Division of the Municipal Court in the county where the Contractor's office is located. Any dispute over the dollar limit of the Small Claims Court arising out of this Agreement shall be submitted to an experienced private construction arbitrator that shall be 10 Contractor Owner_�� mutually selected by the parties to conduct a binding arbitration in accordance with the arbitration laws of the state where the project is located. The arbitrator shall be either a licensed attorney or retired judge who is familiar with construction law. If the parties can not mutually agree on an arbitrator within thirty(30)days of written demand for arbitration, then either of the parties shall submit the dispute to binding arbitration before the American Arbitration Association in accordance with the Construction Industry Rules of the American Arbitration Association then in effect. Judgment upon the award may be entered in any Court having jurisdiction thereof. The prevailing party in any legal proceeding related to this Agreement shall be entitled to payment of reasonable attorney's fees, costs, and post judgment interest at the legal rate. ENTIRE AGREEMENT, SEVERABILITY, AND MODIFICATION This Agreement represents and contains the entire agreement and understanding between the parties. Prior discussions or verbal representations by Contractor or Owner that are not contained in this Agreement are not a part of this Agreement. In the event that any provision of this Agreement is at any time held by a Court to be invalid or unenforceable, the parties agree that all other provisions of this Agreement will remain in full force and effect. Any future modification of this Agreement should be made in writing and executed by Owner and Contractor. 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. 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 TELEGRAM 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 of the entire Agreement and attached Addenda. Contractor may not start work until after this Agreement has been signed. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS IS A LEGALLY BINDING AGREEMENT. IF THERE ARE ANY PROVISIONS WHICH YOU DO NOT UNDERSTAND, YOU SHOULD CONSULT WITH ANA TTORNE Y BEFORE SIGNING. KEITE ILDERS, INC. (CONTRACTOR) OWNER of-/3 t.Sc,,47, Biter, President Date Date Date Contractor Owner