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36-210 CERTIFICATE OF LIABILITY INSURANCE 1 VN1O "r'MuU"rIII 06/01/2012 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 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 NAME Webber & Grinnell Ins. Agency, Inc. PHONE Exq 4 13. 586.0111 i FAX C No1 _.413. 586.6481 8 North King Street ADDRESS Northampton, MA 01060 PRODUCER 00021099 mP CUSTOMER IQ a INSURER(S) AFFORDING COVERAGE NAIC 0 INSURED INSURER A. Travelers Casualty of America Keiter Builders, Inc. INSURERB - Travelers Indemn. Co. CT 1 25682 51A Hatfield Street INSURERC: Northampton, MA 01060 INSURER D : INSURER E : i INSURER F : I COVERAGES CERTIFICATE NUMBER: Master Exp 06/13 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. R _._ " .---- ' - " - T PO LICYEFF T POLICY EXP I - -- ADDL; WVO ' ., - LTR '', POLICY NUMBER i (MMIDONYYY) DIW (MMlDYY) _ _ GENERAL LIABILITY TM F INSURANCE ' "sR `"" �D I6806319N661AC712' 06/01/2012:06/01/2013! LIMITS - . 1 t 1,000,000 " F 300,000 X 5,000 A - t 1,000,000 F_.._ t 2,000,000 = 2,000,000 It AUTOMOBILE E LIABILITY I -, I ,, -t ■ { I , — i UMBRELLA LIAR EXCESS LIAB rF ) r WORKERS COMPENSATION IEUB2A56578212 ',06/1112012:06111 /20131 I I - _; AND EMPLOYERS' LIABILITY YIN - -- _ -- - -. - -I Pe t ..H. . , I ''' 100,000 B I,t �. ,Ft ( t I ti _.:NIA - t , 1 -.I- I -t r, 100 1 (Mandatory in NH) j -- -- - -� -- r ,u- E L . I L F. , 500,000 DESCRIPTION OF OPERATIONS( LOCATIONS (VEHICLES (Attach ACORD 101. Additional Remarks Schedule. it 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0+0- 44044x✓ -. For Information Only "***'° Cynthia Henderson, CISR /CINDY © 1988-2009 ACORD CORPORATION. All rights reserved. The Commonwea of Massachusetts Print Form Department of Industrial Accidents , :; _ --` Office of Investigations t. 1 Congress Street, Suite 100 � W Boston, MA 02114 -2017 �`� • ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 4, TCK .ti 1 �4 CMG S , .Z/-C . Address: 51 1-I A, rf tc c., S . City /State /Zip: t o a.Tt +A ii - T - bt/`i Wk/ Phone #: 1 -1/3 ' 3 4. 1(ke0 o Are you an employer? Check the appropriate box: Type of project (required): , 1. " am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ['Demolition working for me in any capacity. employees and have workers' y ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.11 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 1.52, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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: 1 (L t.£it.-S Policy # or Self -ins. Lic. #: J.- e U (3 a . A S1 S'7$ L\ Z - Expiration Date: (o - l 1 - / 5 Job Site Address: 11 O vac H 1_ -tom City /State /Zip: VI -oi{- N4 610 bZ 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. I do hereby ify un r e pains and penalties of perjury that the information provided above is true and correct D Signatur • g- /7t ,D,14, C. Date: / — .2 3 - / 3 Phone #: 9 [ 3 • f81,. • Raoo 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 #: 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 AL'T'ERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. THE RIGHT TO INITIATE AL'T'ERNATIVE DISPUTE RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THIS AGREEMENT. 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. RIGHT TO CANCEL CONTRACT: 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 Exhibits. Keiter Builders, Inc. 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. HOMEOWNER 1%22 . 1"17 ///20) by, ott Keiter, its president Date Date Date 5 L SCOPE OF WORK January 22, 2013 CUSTOMER NAME: Mark & Cindy Shepard ADDRESS: 17 Birch Lane Florence, MA 01062 PROJECT ADDRESS: 17 Birch Lane Florence, MA 01062 ESTIMATED START DATE: March ls`, 2013 ESTIMATED PROJECT RUN TIME: 4 - Days ADMINISTRATION • Keiter Builders, Inc. will manage the following aspects of the project: o Building permit application o Standing all necessary inspections o Materials ordering and delivery o Site set -up and break -down WINDOWS (Please see attached Marvin Quote # QCM857W for all window specifications) THIS CONTRACT INCLUDES THE FOLLOWING o Building permit application and fees o Removal and disposal of (18) existing window sash pairs o Prepare openings to accept new Marvin wincoow inserts as specified in attached Marvin quote o Install (11) new Marvin window inserts �Sjj o Install all necessary caulking and low expansion foam insulation around new window inserts o Install frame expanders around top and sides of all new window inserts o Furnish and install single piece of pine molding (type t.b.d.) around new window inserts o Install low expansion foam insulation around (19) existing window frame units. Owner to do all preparation, and re- installation of interior casing o Please note that this contract does not include any filling of nail holes, interior fmish caulking, putty, stain, or other finishes TOTAL PRICE FOR ALL MATERIAL AND LABOR: $17,844.49 11125) 1").1 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction C T '4.5 Supervisor: Not Applicable — Name of License Holder : Jcc 7 " r te- ) O. License Number 51 A PO i Si NttiT -1. tu,jT3ly MA Olo(.o •.2 o a Ol Addre 1 Expiration Date 91 3. 5I(0 . S Si ure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ It 3�95 Company Name Registration Number �I Lt S mac. (o • (• 2013 Address Expiration Date I' 01060 7�I Etb s r Alon7 j AAA Telephone y7j 2f) .GCO 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 bui .ing permit. Signed Affidavit Attached Yes A . - ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or faun structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachuse s General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and ass s responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Loc. r oning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement endows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [Ell Brief Description of Proposed Work: 1 26 c\ -ACEn tbv i U % NZJ O c.).S Cl rLrSE-1.T. l Alteration of existing bedroom Yes No Adding new bedroom Yes °.`" No Attached Narrative Renovating unfinished basement Yes V— 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 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. .ZEASE Ce; 0111C F+E0 1 Sr.rvel)____ ov.-c c T'. Signature of Owner Date S cn - - T:/ , 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. S GOT ker?Zv' Print Name 1 - / zik 1.(c.7:06KS •c. /• a3 • a Sig • e of 0 ner /Agent Date Amorminommummummiew Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage ° Io Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces till: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O ,Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YE: O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: a .. Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability JAN 25 Room 100 WaterANeli Availability Northampton, MA 01060 Two Sets of Structural Plans oe o c pftbne 413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans NcRTHAr r ON n,: , u, Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 1 7 91+26 Id LtN L Map Lot Unit otiC- >n,cetvtA 8t 06Z Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 0.-)1>y Sr-4E 17 i31)2c4 L E Ti_orte,vce MA } Name (Print) Current Mailing Address 3 • y „ 7g, !coy- Telephone Signature 2.2 Authorized Agent: /(6 t. di L. 77t s , Eiv c . 47 A tM I Fly.. b ST. h o k-T >t-tyiaN MA- ) N. (Print) Current Mailing Address: , s , - yf3. s • 8c. o c. ig = ure 7 Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 71 $ �� (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) l 7, R9c1-,4 ' Check Number 0447 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 17 BIRCH LN BP- 2013 -0719 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 210 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP-2013-0719 Project # JS- 2013- 001214 Est. Cost: $17844.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT KEITER 102457 Lot Size(sq. ft.): 77101.20 Owner: SHEPARD MARK R & CYNTHIA L Zoning: Applicant: SCOTT KEITER AT: 17 BIRCH LN Applicant Address: Phone: Insurance: 51A HATFIELD ST (413) 320 -9035 WC NORTHAMPTONMA01060 ISSUED ON:1/25/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 19 REPLACEMENT WINDOWS 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 1/25/2013 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner