38B-066 (12) BP-2021-1978
251 SOUTH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-066-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1978 PERMISSION IS HEREBY GRANTED TO:
Project# REPAIRS Contractor: License:
Est. Cost: 65000 102457
Const.Class:. Exp.Date:06/20/2022
Use Group: Owner: MALINOWSKI, REBECCA S.
Lot Size (sq.ft.)
Zoning: URB Applicant: KEITER CORPORATION
Applicant Address Phone: Insurance:
35 Main St. (413)586-8600 0 MCC200200053820121A
FLORENCE, MA 01062
ISSUED ON:10/06/2021
TO PERFORM THE FOLLOWING WORK:
REPAIRS TO FOUNDATION
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.
Signature:
I . fry )2 . I .
( I �
Fees Paid: $423.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Plans i vt Qhita
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The Commonwealth of M sach setts l
FOR
,, Board of Building Regulatio and standards 4 20491 CIPALITY
Massachusetts State Building ode 4
' NOR• USE
Building Permit Application To Construct,Repair, r U��DA�:.: h evised Mar 2011
One- or Two-Family Dwelling '04401 osoionrs
This Section For Official Use Only
Building Permit Number: a(tea I"/y71 Date Applied:
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Ata
Building Official(Print Name) Signature —_
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
251 SOUTH STREET
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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:
Zone: _ Outside Flood Zone?Public Private 0 Municipal On site disposal system 0
Check if yes®Check
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner'of Record:
Rebecca Malinowski Northampton, MA 01060
Name(Print) City,State,ZIP
251 South Street 248-225-6933 beckv.nalinowskirgmaii.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 0 Repairs(s) Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
Remove and disnose of concrete and block foundations below porch and bedroom, and install new viers,
posts.and LVL beams,
Repaint and replace CMU blocks and bricks as needed and apply a stucco finish to west side foundation of
house SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
, (Labor and Materials) Official Use Only
1.Building $ 65,000 1. Building Permit Fee: $ 423 Indicate bow fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier 65 x 6.5
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees:$
Check No I L(6(heck Amount. —t )"Cash Amount:
6.Total Project Cost: $ 65,000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-102457 6/202")
Scott Keiter License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
.,no Street
tt Type Description
No.andd Street
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 ski item keiterbDifaers corn I Insulation
Telephone Email address D DemoIition
5.2 Registered Home Improvement Contractor(HIC)
175188 4.r28721
Keiter Builders, Inc. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
35 Main Street skeiter@keiterbuilders.corn
No.and Street Email address
Florence,MA 01062 471 a5-+R600
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 El
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 Keiter Builders
to act on my behalf,in all matters relative to work authorized by this building permit application.
See the attached signed contract 9/28�21
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
conned in this application is true and accurate to the best of my knowledge and understanding. .
Y/ 1
r /�✓� President, KBI 9128/21
rant 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.nlass.gov/oca Information on the Construction Supervisor License can be found at www.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 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
•
Boston,MA 02114-2017
ww► .mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Keiter Corporation
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):
I.Q I am a employer with 38 employees(full andlorpart-time).* 7. 0 New construction
2.01 am a sole proprietor or partnership and have no employees working for me in 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. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑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. p
❑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•❑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.Lie.#: MCC20020005382021 A Expiration Date: 6:11:2022
Job Site Address: 251 Sn;,th st 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.
1 9/28/21
Signature: U i,/�' 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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
! , "
ACC: CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
06/16/2021
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 (413)586-0111 FAX (413)586-6481
(A/C,No,Ext): (A/C,No):
8 North King Street E-MAIL chenderson@webberandgrinnell.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259
•
INSURED INSURER B: MA Employers/A.I.M. 12886
Keiter Corporation INSURER C:
Attn:Scott Keiter INSURER D:
35 Main Street INSURER E:
Florence MA 01062 INSURER F
COVERAGES CERTIFICATE NUMBER: Master Exp 2022 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 (MMIDD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 500,000
CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $ 15,000
A S2265567 06/01/2021 06/01/2022 PERSONAL snovINJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY JE o LOC2,000,000
PRODUCTS-COMP/OPAGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
X ANY AUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED A9105217 06/01/2021 06/01/2022 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 06/01/2021 06/01/2022 AGGREGATE $ 5,000,000
DED X RETENTION $ 0 $
WORKERS COMPENSATION X STATUTE X ORTH-
AND EMPLOYERS'LIABILITY
Y N
B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A MCC20020005382021A 06/11/2021 06/11/2022 E.L.EACH ACCIDENT $ 1,000.000
OFFICER/MEMBER EXCLUDED?
(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 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
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