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16A-002-002 (2)
BP-2022-0903 300 NORTH MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16A-002-002 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-2022-0903 PERMISSIONISHEREBYGRANTE TO: Project# ROOF Contractor: License: Est. Cost: 164000 KEITER CORPORATION 102457 Const.Class: Exp. Date:06/20/2024 Use Group: Owner: LOOK PARK LOOK MEMORIAL PAR Lot Size (sq.ft.) Zoning: URB Applicant: KEITER CORPORATION Applicant Address Phone: Insurance: 35 MAIN ST,2ND FLOOR (413)586-8600 MCC20020005382021A FLORENCE, MA 01062 ISSUED ON:08/01/2022 TO PERFORM THE FOLLO WING WORK: INSTALL ROOF MEMBRANE AND DECKING OVER STAGE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL TION OF ANY OF ITS RULES AND REGULATIONS. Signature: ' ' , GI) I ' 1 Fees Paid: $1,148.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED Pis AUG - 1 2022 ThEl Commonwealth of Massachusetts j 1. 4: I Office of Public Safety and Inspections ` L I Massachusetts State Building Code(780 CMR) t"'i OF BbaiblitWer bi pHc ation for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:2L• go, Date Applied: Building Official: Look Park - Pines Theater SECTION 1:LOCATION 300 N. Main Street, Florence, MA 01062 No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used 901 If New Construction check here❑or check all that apply in the two tows below Existing Building 0 Repair 0 Alteration C3 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes El NO 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No Brief Description of Proposed Work Installation of roof membrane and decking system over the existing concrete slab stage ThP prnjart also includes miner sitework associated with the stage perimeter. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) NA Total Area(sq.ft.)and Total Height(ft.) NA SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-300I R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA El IB ❑ hA ❑ IIB ❑ IIIA ❑ IUB ❑ IV El VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Ibis osal Site ] Public ER Check if outside Flood Zone El Indicate municipal 121 A trench will not be p required gl or trench or specify: Private 0 or indentify Zone: or on site system❑ permit is enclosed 0 USA Waste Railroad right-of-way: Hazards to Air Navigation: i 1A Historic Commission Review Process: Not Applicable D Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes 0 or No 11 Yes El No RI SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Look Memorial Park CIO Jillian Larkin 300 North Main Street, Florence, MA 01062 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Director 413:586 2882 _ _ jlarkinC@-lookpark.org Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Keiter Corporation 35 Main Street Florence, MA 01062 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hereR. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) • Garth Schwellenbach 411—C49_3616 Barth(@@candharchitects.com 951084 Name(Registrant) Telephone No. e-mail address Registration Number N Pi,eflc,anJ St Amherst; MA 01002 Arch 8/31/22 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Keiter Corporation Company Name Scott Keiter CS-102457 Name of Person Responsible for Construction License No. and Type if Applicable 35 Main Street Florence, MA 01062 Street Address City/Town State Zip �1 586 8600 413 320. 9035 skeiter@keiterbuilders.com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes El No D SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 164,000 1.Building $ 160,400 Building Permit Fee=Total Construction Cost x 7 (insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 3,600 4.Mechanical (HVAC) $ Note:Minimum fee=$ 1,148(contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 164,000 (contact municipality)and write check number here .2 4/1/7/ SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicatio., V. e an accurate to the best of my knowledge and understanding. r ' Scott Keiter, President 413-586 3600 7/26/22 Please p . t and sign name Title Telephone No. Date 35 Main Street. Forence, MA. 01062 skeiter@keiter.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: \ Name 1� The Commonwealth of Massachusetts Department of Industrial Accidents =" J_ > 1 Congress Street,Suite 100 Boston, MA 02114-2017 ° 'WEIR 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): Keiter Corporation Address: 35 Main St City/State/Zip: Florence, MA 01062 Phone#: 413-586-8600 Are you an employer?Check the appropriate box: Type of project(required): l.®I am a employer with 65 employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. X❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. Demolition 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. i 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.❑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 indicati g 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.#:MCC20020005382022A Expiration Date: 6/11/23 Job Site Address: 300 N. Main St City/State/Zip: Florence, MA 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$11,500.00 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 under e ins and penalties of perjury that the information provided above is true and correct. Signature: 1'i�4s,4L.- e8Z Date: 07.26.22 Phone#: 413-586-8600 ti 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#: 4vow, The City of Northamp ton `4.M= ,r-`` Building Departmentr.,:,, __a , 212 Main Street 0R" °'°"00 Northampton, Massachusetts 01060 Phone (413) 587-1240 Fax (413) 587-1272 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVAT ION PROJECTS) In accordance with the provisions of MGL c40, 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, s150A. The debris will be disposed of in: Valley Recycling Location of Facility Easthampton St Northampton, MA The debris will be transported by: USA Waste Name of Hauler USA Waste 1 Signature of Applicant: \ Date: 7-26-22 ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°D/YYYY) 06/07/2022 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 2023 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. 1 INSR ADDL SUBR POLICY EFF POLICY EXP i LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE j $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A S2265567 06/01/2022 06/01/2023 PERSONAL&ADVINJURY $ 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000.000 POLICY PE° LOC PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person $ A - OWNED SCHEDULED A9105217 06/01/2022 06/01/2023 BODILY INJURY(Peraccideryt) $ 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 { $ 10,000,000 A - EXCESS LIAB S2265567 06/01/2022 06/01/2023 1 10,000,000 �/ CLAIMS-MADE AGGREGATE I $ DED X RETENTION $ 0 _ _ �/ �/ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA MCC20020005382022A 06/11/2022 06/11/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 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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