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31A-233 (2) 17 KENSINGTON AVE BP-2020-0889 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-233 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: renovation BUILDING PERMIT Permit# BP-2020-0889 Proiect# JS-2020-001514 Est.Cost: $119000.00 Fee:$774.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sg. 111 7884.36 Owner: Melinda MASON Zoning: URB(100)/ Applicant. KEITER BUILDERS AT. 17 KENSINGTON AVE Applicant Address: Phone: Insrnran ce: 35 MAIN ST (413) 586-8600 U WC FLORENCEMA01062 ISSUED ON.2/4/2020 0:00.00 TO PERFORM THE FOLLOWING WORK.-RENO TO KITCHEN, BEDROOMS AND BATHS 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 2/4/2020 0:00:00 $774.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner k Department use only City of Northampton/' orthampton Sta of Permit: Building Department �. 6/CiDriveway Permit 212 Main Stree �Q Sewe epticAvailability Room 100 �T c�(,)a Wate/Well¢( ailability Northampton, MA 01�0d`Q?r,,� Tw Sets 'f Structural Plans phone 413-587-1240 Fax 413 587; . PI t/Site fans h e ��� ��� her S ecify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR-DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 9&�bd­ 1.1 Property Address: This section to be completed by office 3 Map Lot Unit 17 Kensington Ave Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current W � ,_,po.----�o C o Current Mailing Address: ki-Auk J�71�� Telephone Signature 2.2 Authorized Agent: Keiter Builders, Inc. 35 Main Street Florence, MA 01062 Nam rint) Current Mailing Address: Prs, 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 GIs- (a) Building Permit Fee �e1 2. Electrical v (b) Estimated Total Cost of GT �O 't5kz Construction from 6 fit_\ K 3. Plumbing 4;L"4 „4 WD Building Permit Fee ��� 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2 +3 +4 + 5) Check Number This Section For Official Use Only U �Q g Building Permit Number: Datel� Issued: Signature: `7 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 177 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other[O] Brief Description of Pr posed Work: '�ey►o.ra�rt.�. -}O k� -c�tt� baYoo.�s i 1oc���•w� Alteration of existing bedroom ✓Yes 9 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 ,lh A-A_ as Owner of the subject property hereby authorize KPit r B iildPrs Inc to act on my behalf, in all matters relativ to work authori ed by this building permit application. 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 K iter Print N P- , 01.21.2020 Sign Rre 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 413-586-8600 Signature• Telephone 9. Realstered Home Improvement Contractor: Not Applicable ❑ Keiter Builders, Inc. 175168 Comlany 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- 41 y:. fie . ' 212 Main Street •Municipal Building ' Northampton, MA 01060 '��V;'• 'Y,)\ . 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: 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) 01.21.2020 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 9.3 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 : Florence, MA 01062 Phone #: 413.586.8600 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 arrt a employer with 25 4. ® I am a general contractor and 1 6. ® New construction employees (full and/or part-time).* 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 no employees These sub-contractors have g, 0 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.® Electrical repairs or additions 3.® I am a homeowner doing all work officers have exercised their 1 1.® 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 Addition 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 1140 KensingtonNorthampton 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. 1 do hereby rtify�the pains and penalties of perjury that the information provided above is true and correct. 01 .20.2020 Signato 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/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone #:_ A�RCI® DATE(MM12019 V) CERTIFICATE OF LIABILITY INSURANCE os/o3zo19 THIS CERTIFICATE IS ISSUED ASA 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(les)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 PHOIC,NE EktI. (413)586-0111 Aic No: (413)586-6481 8 North King Street aoD ESS: chenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC M Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: A.I.M.Mutual/A.I.M. Ke(ter 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYri MMIDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE Fx_]OCCUR PREMISES a 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 O- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY❑JE a ROTHER: AUTOMOBILE LIABILITY Ea acccf BINe0 SINGLE LIMIT $ 1,000,000 IANY AUTO BODILY INJURY(Per person) $ OWNEDX SCHEDULED A9105217 06/01/2019 06/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED XNON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acci en Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESSLIIAR CLAIMS-MADE S2265567 06/01/2019 06/01/2020 AGGREGATE $ 5,000,000 X DED RETENTION$ 10'000 $ WORKERS COMPENSATION X PIAT T X ERH- A AND EMPLOYERS*LIABILITY YIN 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? NIA MCC20020005382019A 06/11/2019 06111/2020 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/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 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. KEITER BUILDERS, INC. (CONTRACTOR) OWNER ' 1 2-v , By Scott Keiter, President Date Date 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 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 theartier. Prior discussions or 10 Contractor Owner 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 TTORNEY BEFORE SIGNING. KEITER BUILDERS, INC. (CONTRACTOR) OWNER _ ham ( ZOO by, Scott Keiter, President Date Date Date 11 Contractor Owner