31D-164 (2) = KEIT/Ere
B1JILDERS SlA Hatfield$tf■.el.iNofthampton•MA•01CtiO•Phone 413 586 60)0ot-3x:413 280 0124•keiterbuilders.corn
June 19,2013
Mr. Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton,MA 01060
Dear Mr. Hasbrouck:
I request that you grant a modification to waive the requirement for control construction for the project at 220 Main Street in
Northampton because the work is of minor nature,will not affect health,accessibility,life and fire safety,or structural
requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the
proposed work. Thank you for your consideration.
Respectfully.
-0"
Sc. •A.President
Keiter Builders,Inc.
51A I latfield Street
Northampton.MA 01060
„”, e
A�_°K° CERTIFICATE OF LIABILITY INSURANCE 6�11`i o°3YY'
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(fes)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 Cynthia Henderson, CISR
Webber & Grinnell (= ea: (413)586-0111 ((FAJC No):(413)586-6481
8 North King Street
EMAIL
ADDRESS
_chenderson8mebberandgrinnell.con
NSURER(S)AFFORDING COVERAGE NAIL
Northampton MA 01060 Nnstelw Travelers Companies, Inc_
INSURED
mammas-Citation 40274
Keiter Builders, Inc. Nsunenc:Travelers Indemn. Co. CT 25682
51A Hatfield Street INSURER D:
INSURER E:
Northampton MA 01060 ISURERF:
COVERAGES CERTIFICATE NUMBER1IIaster Exp 12/13 REVISION NUMBER:
This IS TO CERTIFY THAT THE POUCIES 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.
IR TYPE OF INSURANCE RSA VIVO POLICY NUMBER Jig ADO YYYY
LTR YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL uABlurr PREMISES(Ea occurrence) $ 300,000
A I CiAMMSMADE I I I OCCUR 680631956611342 6/1/2013 6/1/2014 N E D ap one p ) $ 5,000
PERSONA-&ADV INJURY_ S 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENII AGGREGATE OMIT APPLIES PER: PRODUCTS-COEFIOP AGG $ 2,000,000
i1POLICYI IFEa nLOC s
AUTOMOBILE LIABIJTY COMBINED SINGLE UNIT
(Ea accident) $ 1,000,000
B ANY AUTO BODILY INJURY(Per person) $
ALL OWNED x SCHEDULED 12)OIBCDRO7 12/21/201212/21/2013 NOO.LYINJURY(per accident) $
AUTOS AUTOS
I FIRED AUTOS x Al (Per accident) T. _
Medical paymenis $ 5,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _
EXCESS LIAB CLAMS-MADE AGGREGATE $
DED 1 I RETENTIONS $
C WORKERS COMPENSATION I TORY UNITS I I ER
AND EMPLOYERS LIABILITY Y I N
ANY PROPRIETORIPARTIR/EXECUTIVE I I N/A EL EACH ACCIDENT S 100,000
OFFICER/MEMBER R EXCLUDED? 18052A56578213 6/11/2013 6/11/2014
M)
(Mandatary in N EL DISEASE-EA EMPLOYEES 100,000 descnbe under
If DES RIIPTION OF OPERATIONS below _ E.L DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,II more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
***** For Information Only ***** ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
C Henderson, CISR/CIN .5100,41-041L-. .+seet0'r.°er�.j
ACORD 25(2010105) c 1988-2010 ACORD CORPORATION. All rights reserved.
INS()9.S oninnch ni The.A1_I DA narrhn at net Irvin aro rnn:e*nrort marl,.chi scvma V
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 ALTERNATIVE 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.
Owner understands and acknowledges that Keiter Builders, Inc_ may use any photos taken during the course of
work for promotional purposes_ This may include, but is not limited to, the following: Website, newspapers,
journals,magazines, posters,and flyers.
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_ OWNER
l?r;;".4-
(17' il-% /70,1efigpoPi)
by, tt Keiter, President Date (7324/4- pale
Date
5
r4
kk ! BUILDERS'
SCOPE OF WORK
_
June 7.2013
CUSTOMER NAME: Unitarian Society of Northampton
ADDRESS: 220 Main Street,Northampton.MA 01060
PROJECT ADDRESS: 220 Main Street,Northampton,MA 01060
ESTIMATED START DATE: Summer,2013
ESTIMATED PROJECT RUN TIME: 2 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 Safety&Security
o Site set-up and break-down
AWNING
This proposal includes the following:
• Building permit fee.
• Staging set-up and breakdown_
® Remove,and dispose of,existing shingles step flashing and other miscellaneous debris.
• Cut open sheathing to review the following: (Report to Owner)
o Structural integrity of rod I bolt connections to roof assembly.
o Condition of all concealed framing members.
• Reinstall sheathing to cover openings.
• Visually review condition of rod/bolt connection to masonry.—Report to Owner.
• Install continuous Grace Ice&Water membrane across entire roof area
■ Properly seal both rod penetrations using Lexel or equivalent.
■ Install drip edge around perimeter of roof area.
• Install 30 year Architectural Shingles and ridge cap.
• Install conventional step flashing.
• Install copper counter flashing seated/sealed into brick mortar_
• Remove and replace(3)pieces of rotted trim on inner side of boxed frame.
• Site will be left in clean condition—magnets used to confirm no nails in lot
• Please note that the following items are not included in this proposal:
o Any rot repair beyond(3)pieces of trim--pending review.
o Any paint,stain,filling of nail holes or other finishes_
TOTAL PROJECT COST INCLUDING MATERIAL AND LABOR: $1,785.00
r �
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.Pursuant to
this statute,an employee is defined as"...every person in the service of another under any contract of hire,express or implied,oral or
written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the
foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an
individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not
more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do
maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because
of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a
license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced
acceptable evidence of compliance with the insurance coverage required."Additionally,MGL chapter 152, §25C(7)states
"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,
supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability
Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to
carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit
may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.Also be sure to sign and date
the affidavit.The affidavit should be returned to the city or town that the application for the permit or license is being requested, not
the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance
license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must
submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy
information (if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy
of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid
affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is
obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said
person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,please do
not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, 02114-2017
Tel. 617-2017-4900 Ext. 406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Revised 7-2010
Z:\Workers Comp Aff-Highlited.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
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): K moult-0ETZ• 1 1►.1e .
Address: 5 1 A t f c t LID ST'
City/State/Zip: NIOt2TH-At'AlPTN MPc OtObO Phone id: "`t13-a8G-861f3°
Are you an employer? Check the appropriate box: Type of project(required):
1.tin I am an employer with 3 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors 7. ❑ Remodeling
listed on the attached sheet.
2. ❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition
ship and have no employees employees and have workers' 9. ❑ Building addition
working for me in any capacity. comp. insurance.:
[No workers' comp.insurance 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
officers have exercised their 11.❑ Plumbing repairs or additions
3. ❑ I am a homeownerSeattle8 doing right of exemption per MGL c. 12.❑ Roof repairs
all work myself. [No workers' 152, §1(4),and we have no
comp. insurance required.] t employees. [No workers' 13.❑ Other Pk-1 Nt N Ca t2EP/41 t2,
comp. insurance required.]
*My 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: "1IZ M1 Le.es
Policy#or Self-ins.Lic.#: S E U B 2A 5(05 78 2l 2 Expiration Date: !o • 1 1 . 2014
Job Site Address: 220 ■ A-11■I ST2Cel- City/State/Zip: NORTI NitPrOl.i MA- b lobo
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 certify under the pains and penalties of perjury that the information provided above is true and
correct.
Signature: Date: (n 11• WO
i3
Phone #: 1/4.'113-586- 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#:
Z:\Workers Comp Aff-Highlited.doc
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ® No
SECTION 11 -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.
Signature of Owner Date
I, JCAYTT V E rr , ?R I De1.1c K ti (I Lt2� 1�G ' , 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 nains and penalties of perjury.
SCOTT
Print Na i
6. 11. 13
Signature'., OwnerrAgbnt Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .L0T kE ITh2
License Number
JI k 1■1014-ktscmP1t J W OIObO (0- 20 • 201+
Address Expiration Date
Aael .56(0 • 8b00 Sig ture Telephone
SECTION 13-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 75 No
Version).7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name . Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
K1; )1 !NC . Not Applicable ❑
Company Name:
TT-}T✓ITS - pis(psNT
Responsible In Charge of Construction
51 A- 4}1 k T r e t-D NO R T L-+LtP l LAN- a t o(0 a
Ad ss
Sig ure Telephone
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
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 %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOW 4) YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,tdx9�vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: &Al it 6(11-1 1,1 N It461 A-T eN`['RM.IC'I;
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B � ❑
F Factory ❑ F-1 ❑ F-2 0 2C I ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1" 1st
2nd 2nd
3rd 3b
4
4th
4th
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal 0 On site disposal system
Version1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
�� „, Building Department Curb Cut/Driveway Permit
` ti:' �� �� 212 Main Street Sewer/Septic Availability
* Room 100 Water/Well Availability
**0 ��o� Northampton, MA 01060 Two Sets of Structural Plans
o<,�/ phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
o �oQ Other Specify
AP IC ION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
2W Ai11A-IN S-T126&7- Map Lot Unit
NOQT1.FPrl'4PTDM MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
kA liP02.1N14 SOCtt:11M of µOR RA44tInbt l 2Zo MA-04 ST NOILTI�PcMPTmN MPr- otobo
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
SCOTT KStT>;e I ITS t2.. ,tit LC 5, U.. . SI It +MO tE.Lp 3T. (i612.1-4ki\4WMN MP Ottea
Name(Print) Current Mailing Address:
413- 686-860o
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Ilgb.ots (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) 085.e° Check Number 626 07,
I,575
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1188 MC r1 F 0 ' er Ca i
ADDRESS/PHONE 51A HAT IELD STTTNORTHAMPTON (413)320-9035 M6Et W C�
PROPERTY LOCATION 220 MAIN ST 4
MAP 31D PARCEL 164 001 ZONE CB(100)/ €F-° `%
THIS SECTION FOR OFFICIAL USE ONLY: C Pf‘
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �G�C
Fee Paid O
Typeof Construction: REPAIR ROOF OVERHAND ON SIDE ENTRANCE O.CL �C� 1
New Construction \
Non Structural interior renovations i'
Addition to Existing �t 'j
Accessory Structure V c
Building Plans Included: oPs''
Owner/Statement or License 102457
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project:_ Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Dem•lit'. Delay
i /-2a -,75
Signature o C uilding •f icia Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
220 MAIN ST BP-2013-1188
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D- 164 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-1188
Project# JS-2013-001959
Est. Cost: $1785.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SCOTT KEITER 102457
Lot Size(sq. ft.): 3528.36 Owner: UNITARIAN CHURCH
Zoning: CB(100)/ Applicant: SCOTT KEITER
AT: 220 MAIN ST
Applicant Address: Phone: Insurance:
51A HATFIELD ST (413) 320-9035 WC
NORTHAMPTON MAO 1060 ISSUED ON:6/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR ROOF OVERHAND ON SIDE
ENTRANCE *MUST MATCH ORIGINAL EXACTLY* J
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 6/20/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner