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23A-032 (3) 18 MEADOW ST BP-2020-0866 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-032 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 P E RM I T Permit# BP-2020-0866 Project# JS-2020-001485 Est.Cost: $12000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sa.ft.): 22999.68 Owner: PEASE THOMAS R Zoning: GB(100)/ Applicant. KEITER BUILDERS AT. 18 MEADOW ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON.113012020 0:00:00 TO PERFORM THE FOLLOWING WORK.-BUILDING REPAIRS DUE TO CAR HITTING BUILDING 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 1/30/2020 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Version 1.7 Co erci i it May 15,2000 Department use only City of Northampton I of Building Department J Curb Cut/Driv ay P rmit 212 Main Street QN ,3 8eww�rrj�s±eptic vada ility Room 100 nF� Wafe?r`A ailab'ity Northampton, MA 01`060 nn�Fr;ut/n,n. wo Sets of truct ral Plans phone 413-587-1240 Fax 413-587=1 a',, #f6t/ g� ns eci y APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 18 Meadow St Florence - VFW Map ;.,L?y 1-i Lot 6&�)- Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Prin"T Current Mailing Address: Signature Telephone 1t 3- 4r? Ivy-15- 2.2 2.2 Authorized Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Name(Print) Current Mail in Address: 413-584-8600 Signature — Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $7,000 (a) Building Permit Fee ' LA) 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing $5,000 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= 0 +2 +3+4 + 5) 512,000 Check Number This Section For Official Use Only Building Permit Number Date QQ� L0 — , /, Issued Sign lure: v 13oI as Buil ng Commissioner/Inspector of Buil s Date Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑✓ Additions ❑ Accessory Building❑ Exterior Alteration ❑✓ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description Building repairs - damage caused by car hitting building Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 F17 A-2 ® A-3 (] 1A A-4 ® A-5 ® 1B B Business 2A E Educational 2B F Factory ❑❑ F-1 ❑❑ F-2 2C H High Hazard 3A I Institutional ❑❑ 1-1 ❑❑ 1-2 ❑❑ 1-3 ❑❑ 313 M Mercantile 4 R Residential ❑❑ R-1 ❑❑ R-2 ® R-3 ❑❑ 5A S Storage ® S-1 [1 S-2 0 5B U Utility Specify: M Mixed Use Specify: S Special Use Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 St 1st 2nd 2nd 3rd 3rd 4 4t th Total Area(sf) Total Proposed New Construction (sf) Total Height(ft) Total Height ft 7. Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 2 Private ED Zone Outside Flood ZoneR] Municipal ® On site disposal system❑ Version 1.7 Commercial Building Permit May IS,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Depaitment Lot Size Frontave Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage IT (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 O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O 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 O 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 O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial BUildinI1 I'crmit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable EA Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Keiter 13uilderS, Inc Not Applicable 0 Company Name: Scott Keiter Responsible In Charge of Construction 35 Main St. Florence, MA 01062 A ess_ _ , 413-586-8600 President,KBI Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. as Owner of the subject property hereby authorize �, ( '`/�l �� t � to act on my alf, in all matt el�work authorized by this building permit application. Signature of Owner Date Keiter Builders, Inc I, , 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 e "ate 01.27.2020 Sign ure of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Scott Keiter CS-102457 Name of License Holder License Number 51 A Hatheld Street 6/20/20 Ad ss Expiration Date P 413-586-8600 nature Telephone SECTION 13-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 O No O City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 18 Meadow sr The debris will be transported by: Keiter Builders, Inc. The debris will be received by: valley Recycling Building permit number: Name of Permit Applicant Keiter Builder, Inc 1.27.2020 jA �� Presidew.1C131 Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 t� Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Keifer Builders, Inc. Name (Business/Organization/Individual):_ _ _ Address:35 Main Street City/State/Zip: Florence, MA 01062 Phone 4: 413-586-8600 Are you an employer? Chec2 the appropriate box: Type of project(required): 3 1.9 1 am a employer with 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. ® Remodeling ship and have no employees These sub-contractors have g, ® Demolition working for me in any capacity. employees and have workers' 9. ® Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ® We are a corporation and its 10.® 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.® Roof r�eppairs insurance required.] r c. 152, §1(4),and we have no hiepalrs 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 Job site Address: 18 Meadow St City/state/zip: Florence 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 hereby rtifyunder the pains and penalties of perjury that the information provided above is true and correct. 01 .27.2020 Signature. President, K131 Dat e: Phone#: 413-586-860C 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/ Y) CERTIFICATE OF LIABILITY INSURANCE 06/03/20192019 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 Extli (413)586-0111 n/c Ne (413)586.6481 8 North King Street E-MAIL SS: chenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# 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 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 ADDL bUUH POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE F OCCUR PREMISES(Ea occurrence) 500,000 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 0 PELT F LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ AOWNED X SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per accident Medical payments s 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 I X1 RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE X ERH- AND EMPLOYERS'LIABILITY YIN 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? FN] NIA MCC20020005382019A 06/11/2019 06/11/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If ves,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD _ R U I L D `C /Q ) S 35 Main Street-Florence-MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilders.com Commissioner Hasbrouck 1.30.2020 Subject: Request for Waiver _ I request that you grant a modification to waive the requirement for control construction for the VFW Building Repair Project at 18 Meadow St in Florence because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Respectfully, cott Keiter a 1Z Keiter Builders, Inc. 35 Main St Florence, MA 01062