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30A-073 188 WARNER ST BP-2021-1110 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A-073 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-1110 Project# JS-2021-001870 Est.Cost: $30000.00 Fee: $80.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 63597.60 Owner: FREEDENFELD ROBIN B Zoning: URB(100)/ Applicant: KEITER BUILDERS AT: 188 WARNER ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 () WC FLORENCEMA01062 ISSUED ON:4/2/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:REPACE ROOF AND SKYLIGHTS 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. 1 • Ir • . cArt, Certificate of Occupancy Signatur, FeeType: Date Paid: Amount: Building 4/2/2021 0:00:00 $80.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVE 1 APR - 2 2021 1 i The Commonwealth of Massachusetts ^FPT.OF SUILDIgGIt i riCTIONS FOR NORTHAMPIO 1 6. _ ;. Board of Building Regulations and Standards �'�` t, 1,.• Massachusetts State Building Code,780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Fanzili'Dwelling This Section For Official Use Only Buildingpermit Number:C. t c 2 -f i 1 Date Applied: r✓vl� &OS� .//� y-2-20Zi Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 188 War,lo;r Street 30 A 0"73 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: NA NA Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided NA NA NA 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Check ifyes[�l Municipal 0 On site disposal system u SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Robin Freedenfeld Northampton,MA 01060 Name(Print) City,State,ZIP 188 Warner Street buttonstreetassoc@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ® Addition 0 Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Replace roc>`and skylights SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only I.Building $ 30,000 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee l l Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6.Total Project Cost: $ 30,000 Check No.131.01 heck Amount: Go Cash Amount: 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-102457 6/20/22 Scott Keiter License Number Expiration Date Name of CSL Holder List CSL Type(see below) U ,e Main rtroat No.and Street Type Description Florence,MA 01062 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-586-8600 skeiter e e'k�u,l<iei s.,-,m 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 175168 4/28171 Keifer Builders.Inc, HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 35 Main Street ske iter;«'keiterbu!icers.can No.and Street Email address Florence,MA 01062 4.11_c,R6-si6110 City/Town,State,ZIP Telephone SECTION 6: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 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Keifer Builders to act on my behalf,in all matters relative to work authorized by this building permit application. See attached signed contract 3/26/2021 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information confined in this application is true and accurate to the best of my knowledge and understanding. President,Kpl 3/26/2021 Piint Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.govroca Information on the Construction Supervisor License can be found at vmv.mass.gov!dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces NA Number of bedrooms Number of bathrooms Number of half/baths Type of heating system ` Number of decks!porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" NA DocuSign Envelope ID:B81C08BE-69E3-4101-B59B-80E26F627B30 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 • DocuSigned by: DocuSigned by ScoFi- ' 3/15/2021 rV't,tjttn dj 3/13/2021 70134368874VA1... ' C117076C030C402.. 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 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 th provision of this Agreement is at any time held by a Court to be invalid or u efceable, the parties Sk 10 Contractor Owner DocuSign Envelope ID:B81C08BE-69E3-4101-B59B-80E26F627B30 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 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 AN ATTORNEY BEFORE SIGNING. KEITER BUILDERS,INC.(CONTRACTOR) OWNER , DocuSigned by: ,---DocuSigned by: 004 Volvs 3/15/2021 oIejt,t, Fvuj e, 3/13/2021 791343GC07454A1... ' 1-11707CC033C402... by,Scott Keiter,President Date Date Date [ OS 1 1 Contractor Owner The Commonwealth of Massachusetts x Department of Industrial Accidents '_ 1= 1 Congress Street,Suite 100 ..:4— Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMTTTD G AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Keiter Corpora°,gin 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): 1.1:I am a employer with 35 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or parmership and have no employees working for me in g 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. [1]Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised.their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'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 employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lic.#: MCC20020005382020 Expiration Date: 6/11;2021 Job Site Address: IRO,Warner Street 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce fy under the pains and penalties of perjury that the information provided above is true and correct rY�( C✓� 3 262021 Signature: U r 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 6.Other Contact Person: Phone#: A CORE, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYY) 05/29/2020 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 (PHONNE,Ext): (413)586-0111 FAX No): (413)586-6481 8 North King Street E-MAIL chenderson@webberandgrinnell.corn ADDRESS: 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.Keiter Corporation INSURER C: Attn:Scott Keiter INSURER D: 35 Main Street INSURER E: Florence MA 01062 INSURER F COVERAGES CERTIFICATE NUMBER: Master Exp 2021 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE.10 REN r6D 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2020 06/01/2021 PERSONAL a ADv INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JECTO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105217 06/01/2020 06/01/2021 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS MADE S2265567 06/01/2020 06/01/2021 AGGREGATE $ 5,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION X STATUTE X ORTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? N NIA MCC20020005382020 06/11/2020 06/11/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000,000 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