31B-179 (16) ACOR" DATE(MM/DD/YYYY)
�� CERTIFICATE OF LIABILITY INSURANCE 7/10/2015
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 Cynthia Henderson, CISR
NAME: Y _
Webber & Grinnell PHONE (413)586-0111 FAX (413)586-6461
A/C N ___-- A/C No: ._-
8 North King Street ADDRIESS:chenderson @webberandgrinnell.com
INSURER(S)AFFORDING COVERAGE _ __NAIC#
Northampton MA 01060 _ INSURER A Arbella Insurance__Group 17000 _
INSURED INSURER 0:
Keiter Builders, Inc. INSURER C:
Attn: Scott Keiter INSURER D:
35 Main Street INSURER E
Florence MA 01062 INSURER F:
COVERAGES CERTIFICATE NUMBER:Master Exp 2016 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
LT TYPE OF INSURANCE POLICY NUMBER M/DD/YYYY M YYY LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE 1XI PREMISES OCCUR DAMAGE TO ER,=,D.nce $ 300,000
8500064396 6/1/2015 6/1/2016 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER ! GENERAL AGGREGATE $ 2,000,000
X POLICY[:] PRO- ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $ 1,000,000
A ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED 1020039381 6/1/2015 6/1/2016 BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS X AUTOS Per accident $____
Medical payments $ 5,000
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB CLAIMS MADE AGGREGATE $ 1,000,000
DED X RETENTION 10 000 4600064399 6/1/2015 6/1/2016 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N X STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ _100,000
OFFICER/MEMBER EXCLUDED?
A a — ----
(Mandatory inNH) 9127440615 6/11/2015 6/11/2016 E.L.DISEASE-EA EMPLOYE $ 100,000
If yes,describe under -
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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
C Henderson, CISR/CIN
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS095 rontenn
The Commonwealth of Massachusetts
Department of Industrial Accidents
W Office of Investigations
�Q I 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): Keiter Builders, Inc
Address:35 Main Street
Cit /State/Zi : Florence, MA 01062 Phone #:413.586.8600
Are you an employer? Check the appropriate box:
. 1 am a general contractor and 1 Type of project(required):
4
1.19 1 am a employer with 15 g
employees (full and/or part-time).* have hired the sub-contractors 6. ® New construction
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 6 Demolition
working or me in an capacity. employees and have workers'
g y p y• � 9. 0 Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 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. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also till 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:ArlJella
Policy#or Self-ins. Lic. #:9127440615 Expiration Date:6.11 .16
Job Site Address:
25A Henshaw Ave City/State/Zip: Northampton, MA 0-
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 Ice of d r the pains and penalties of perjury that the information provided above is true and correct.
6,1-143 11 .3.15
Si nature• �� , w L Date:
Phone 413.586.
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#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 25 a Hensnaw Ave
The debris will be transported by: Duseau Trucking
The debris will be received by: yauev Recv1cina
Building permit number:
Name of Permit Applicant Keiter Builders, Inc
it. Is-
Date Signature of Permit Applicant
Version 13 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(700 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Gary J,Hartwell
as fawner of the subject property
hereby authorize Keiter Builders, Inc to
act on my behalf,in all att is relative to work authorized by this building permit application.
10/19115
Signature of Owner Dale
Keiter Builders, Inc
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.
Scott Keiter
Print N
r . 3,
Ig t f Owne Agen _ Date
kZ
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Scott Keiter CS-102457
License Number
51 A Hatfield, Street Northampton, MA 01060 06.20.I6
Addres Expiration Date
413.586.8600
S a — 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 No 0
Version 1.7 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:
Laura Fitch Not Applicable ❑
Name(Registrant):
Laura Fitch Registration Number
Address
Expiration Date
Please see attached
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
Keiter Builders, Inc Not Applicable❑
Company Name:
Scott Keiter
Responsible In Charge of Construction
35 Main Street Florence,MA 01060
Address
413.586.8600
Sig a e Telephone
Version 1.7 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
Frontaoe
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 O DON'T KNOW O YES O
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: Filed 10.7.15
C. Do any signs exist on the property? YES O NO 0
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? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 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[:] Change of Use[-] Other❑
Brief Description Demo of interior partition walls,finishes,countertops and doors per attached plans. (attached)
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE Please see the attached plans
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 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 El
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
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)
151 1 St
2nd 2nd
3 rd 3rd
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 El Zone Outside Flood Zone Municipal❑ On site disposal system
rsian 1.7 Commercial Building Permit May 15,2000
Department use only
cOIty of rt mpton status of Permit:
"�'Buildi, partment Curb Cut/Ddveway Permit
�.� ain Street Sewer/Septic Availability
oom 100 WaW/Well Availability
r'. ampton, MA 01060 Two Sets of Structural Plans
ho g -587-1240 Fax 413-587-1272 Plausite Plans
Other Specify
APPLICATION TO CONS RUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map �� Lot ,7� Unit
Capen Annex Zone Overlay District
�A Wpnehmv A up 0 Elan St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
The Trustees of The Smith College , 4, West St.,Northampton, MA 01063
Name(Print) # +C 7V0V1- Current Mailing Address,
585-2441
Signature Telephone
2.2 Authorised Aaent:
Keiter Builders, Inc 35 Main Street Florence,MA 01062 p
Name(Print) Current Mailing Address,.
413.586.8600
Signature "^" Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building (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) Check Number ('
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissionerllns clor of Buildln s Date
File#BP-2016-0619
APPLICANT/CONTACT PERSON KEITER BUILDERS
ADDRESS/PHONE 35 MAIN ST FLORENCE01062(413)586-8600 Q
PROPERTY LOCATION CAPEN HOUSE ANNEX-25A HENSHAW AVE
MAP 3 1 B PARCEL 179 001 ZONE URC(100)/EU(92)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out <.)
Fee Paid
Typeof Construction: DEMO PARTITION WALLS.FINISHES.COUNTERTOPS&DOORS
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 102457 � !lp.�!%C
3 sets of Plans/Plot Plan G
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
emolition Delay
U uild g b ffi cl al 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.
CAPEN HOUSE ANNEX-25A HENSHAW AVE BP-2016-0619
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 179 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-2016-0619
Project# JS-2016-001037
Est. Cost:
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITER BUILDERS 102457
Lot Size(sq. ft.): Owner: SMITH COLLEGE OFFICE OF THE TREASURER
Zoning URC(100)/EU(92)/ Applicant: KEITER BUILDERS
AT. CAPEN HOUSE ANNEX - 25A HENSHAW AVE
Applicant Address: Phone: Insurance:
35 MAIN ST (413) 586-8600 O WC
FLORENCEMA01062 ISSUED ON.111912015 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO PARTITION WALLS,
FINISHES,COUNTERTOPS & DOORS - beam calcs required
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 11/9/2015 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner