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23A-061 (8) 63 MAPLE ST BP-2020-0890 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-061 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING P E R M I T Permit# BP-2020-0890 Proiect# JS-2020-001515 Est.Cost: $15000.00 Fee: $97.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sg.ft.): 12458.16 Owner: 63 MAPLE ST LLC Zoning:GB(100)/ Applicant: KEITER BUILDERS AT: 63 MAPLE ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 0 WC FLORENCEMA01062 ISSUED ON:2/4/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO APMT 2 POST TIiIS 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: FeeTy pe: Date Paid: Amount: Building 2/4/2020 0:00:00 $97.50 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton � � f Permit: Building Department 6u Driyeway Permit 212 Main Streef-:, Q Sewe tic Availability "? Room 100 -1,n��,� c( ater ell �Iatlility / Northampton, MA 010 '� ,,!��, two ets ofucural Plans rr phone 413-587-1240 Fax 413-58T1 � '�, Plo site P ns her S cify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR M ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot 062 Unit 63 Maple St-Apartment 2 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A3 qa& CLC C o Sea 44 I( 35 Me,(_d k S 6g� AM Name in Current M Address: Telephone ((�' �f Sig ature 2.2 u h tzed Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint) Current Mailing Address: PnJ, Jaz- 413-586-8600 SidYature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 12,700 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of k 1 1,500 Construction from 6 3. Plumbing 0 Building Permit Fee - 4. Mechanical(HVAC) qq so 5. Fire Protection 800 6. Total= 0 +2 + 3+4 +5) 15,000 Check Number This Section For Official Use Only Building Permit Number: ®' q�U �D Date Issued: Signature: / 0-10 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 ED Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [O] Other[OI Brief Description of Proposed Work: Renovate apartment 2-New floors, paint, interior&exterior doors,kitchen cabinets&countertops.Overlay drywall on plaster. 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, ;' 6� UtAVy- Crt, IWC �-L as Owner of the subject property hereby authorize Keiter B uildPrs Inc to act on my behalf, in all matters relative to work authorized by this building permit application. �jlI Sig ture of Owne 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 NaM Pti , 02.03.2020 Signre of OwnerlAgent 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 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 Tele phone 413-586-8600 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....... (S No...... ❑ City of Northampton Massachusetts : DEPARTMENT OF BUILDING INSPECTIONS t` 212 Main Street •Municipal Building -� ` Northampton, MA 01060 et 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: 17 Kensington (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) &- ,6/ 1� J�= 02.03.2020 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 y 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 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. 0 1 am a general contractor and 1 6 ® New construction employees (full and/or part-time).* have hired the sub-contractors I 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' y ® 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 work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs insurance required.] r c. 152, §1(4),and we have no 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. I am an employer that is providing workers'compensation insurance for my emplovees. 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: 58 Kensington City/State/Zip: Northampton 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. Ido hereby rtify under the pains and penalties of perjury that the information provided above is true and correct. 02.03.2020 Si n tures President, Keiter Builders, Inc. Date: Phone #: 413.586.8600 Official use only. Do not wrile 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#: �C�© DATE(MMIDDIYYYY) 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 CoNTn11 Cyndie Henderson CISR,CPIA NAME: Webber&Grinnell F'F1C. Extl, (413)586-0111 n/c NOI: (413)586-6481 8 North King Street noliliess: chendersonOwebberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC a Northampton MA 01060 INSURER A: Selective Ins Cc of S Carolina 19259 INSURED INSURER B: A.I.M.Mutual/A.I.M. Keiter 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 ADDLISUEIR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICYNUMBER MMIDDIYYYY MMIDDIYYW X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE TO REN E500,000 CLAIMS-MADE Fx_1 OCCUR PRE ISES Ea occurrence $ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2019 06/01/2020 PERSONAL BADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 PRO 2,000,000 POLICY 1:1 JECT 7 LOC PRODUCTS- OTHER: AUTOMOBILE LIABILITY ED as deD SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNEDX SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED Per accident $ X PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY Medical payments $ 5,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LAB HCLAIMS-MADE S2265567 06/01/2019 06/01/2020 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 �/ $ WORKERS COMPENSATION X STAT TE X ERH AND EMPLOYERS'LIABILITY YIN 1,000.000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? � N/A MCC20020005382019A 06/11/2019 06/11/2020 (Mandatory in NH) E.L.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/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. 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