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36-403 (5) BP-2021-2176 54 EMERSON WAY COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-403-001 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-2021-2176 PERMISSION IS HEREBY GRANTED TO: Project# 2ND FOOR RENO Contractor: License: Est. Cost: 7000 KEITER CORPORATION 102457 Const.Class: Exp.Date:06/20/2022 Use Group: Owner: LIBERTI,RITA& GERTRUDE B TOLL Lot Size (sq.ft.) Zoning: SR Applicant: KEITER CORPORATION Applicant Address Phone: Insurance: 35 Main St. (413)586-8600 0 MCC200200053820121A FLORENCE, IAA 01062 ISSUED ON:11/15/2021 TO PERFORM THE FOLLOWING WORK: FINISH 2ND FLOOR ROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of N iring 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: a' • )2 CP1 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED The Commonwealth of Massachuse s NOV 1 2 2)21 IR 11 Board of Building Regulations and Sta ards `{ MUNP ITY ��"��: ., Massachusetts State Building Code,780 C ` ' �T E Building Permit Application To Construct,Repair,Re ovate()fop is. 0� IN lir bt$Mar 2011 7 MA 01060 One- or Two-Fanu755 Dwelling --— This Section For Official Use Only Buildinn Penult Number6P-.a.,)~ Al 7(0 Date Applied: IEU1 - 1Z 2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 54 Emerson .. I.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: Public El Private 0 Zone: _ Outside Flood Zone? Municipal El On site disposal system 0 Check if yesEl SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Rita Liberh& Gertrude Toil Northampton, MA 01060 Name(Print) City,State,ZIP 54 Emerson•\Va"v tourg':rls1guy@comcast.net 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) 0 Alteration(s) O Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Fin shina an unfinished room on the 2nd floor by adding recessed hailing. drywall. Hi,-AEC ducting and electrical and trim: SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Labor and Materials) Official Use Only 1.Building $ 4,000 1. Building Permit Fee: $ 65 Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical S 1,000 0 Total Project Cost'(Item 6)x multiplier 7 x 6,5 3.Plumbing S 2. Other Fees: S 4.Mechanical (HVAC) $ 2.000 List: 5.Mechanical (Fire $ Suppression) Total All Fe $ Check Noi1heck Amounb6 Cash Amount: 6.Total Project Cost: $ 7,000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-1024;, 6(20/22 Scott Kee License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description 1 nren e, MA 01062 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 18:2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 4 3_585-8600 sKeite . ,r, to u L ders.cc m I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(MC) "' inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 35 Main Street skeiter@keiterbuliciers,com No.and Street Email address 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 0 No ❑ 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 Ke t o Corporation to act on my behalf,in all matters relative to work authorized by this building permit application. See the attached signed contract '1.-':.0.21 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 co fined in this application is true and accurate to the best of my knowledge and understanding. . /G✓/— K 1.1n 21 Tint 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.ggov,'oca Information on the Construction Supervisor License can be found at www.mass.aovldps 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"maybe substituted for"Total Project Cost" \ The Commonwealth of Massachusetts Department of Industrial Accidents - o 1 Congress Street,Suite 100 t • Boston,MA 02114-2017 � `% www 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) t `>i:` ,3n Address: 35 fv"i:lin S,reet City/State/Zip: Florence. MA 01062 Phone#: a 13-586-8600 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or parmersbip and have no employees working forme in g 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Reof repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑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.] sy��,�,,i' *Any applicant that checks box#1 must also fill out the section below showini-{crreCt3rperrsation 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 n Expiration Date: 6/11/2022 Job Site Address: 5; Emerson Way City/State/Zip: Norttiam 3tyn 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. Sienature: r ,6-'�,' Date: 11.1021 Phone#: 41 3-586-8600 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#: ACORCI® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 PgHONr o,EXt): (413)586-0111 FAX No): (413)586-6481 8 North King Street E-MAIL chenderson@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INsuRERA: 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1000000 �/ 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&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY J LOC PRODUCTS-COMP/OPAGG $ 2'000'000 — OTHER: • $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ,4 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 EORH AND EMPLOYERS'LIABILITY Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A MCC20020005382021A 06/11/2021 06/11/2022 E.L.EACH ACCIDENT 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/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(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton Massachusetts l'4', ,:,4,i it; DEPARTMENT OF BUILDING INSPECTIONS = W 212 Main Street • Municipal Building Northampton, MA 01060 ik,, 1 ,," CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: V<ille. Rem/cling The debris will be transported by: Name of Hauler: KeiterCorporation Signature of Applicant: :!J� Date: ' , ,,