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23A-061 (3) 63 MAPLE ST BP-2018-1078 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A-061 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv:demolition BUILDING PERMIT Permit# BP-2018-1078 Project JS-2018-001944 Est. Cost:$3000.00 Fee: $50.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(su.ft.): 12458.16 Owner: KEITER SCOTT Zoning: GB(100) Applicant: KEITER BUILDERS AT: 63 MAPLE ST Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 O WC FLORENCEMA01062 ISSUED ON.4/2512018 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO OF INTERIOR SPACE TO PREPARE FOR OFFICE RENOVATION 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: O_I: 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: FeeTyoe: Date Paid: Amount: Building 4/25/2018 0:00:00 $50.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1078 APPLICANT/CONTACT PERSON KEITER BUILDERS ADDRESS/PHONE 35 MAIN ST FLORENCE (413)5864600(1 PROPERTY LOCATION 63 MAPLE ST MAP 23A PARCEL 061 001 ZONE GB(I00 THIS SECTION FO+ OFFICIAL USE ONLY: PERMIT APPLICATION(IfECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid _ Buildin Permit Filled out ___ Fee Paid Tvneof Construction: DEMO OF INTERIOR SPACE TO PUPARE FOR OFFICE RENOVATION New Construction _ Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 102457 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEJ4 ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project Site Pip 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 Pet:nit 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 Bound of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commis on Permit DPW Storm Water Management Demolition Delay r ature ofB riding .'al Date Note: Issuance of a m rg permit does or 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 MOL 40A.Contact Office of Planning&Development for more information. Vereimi Commercial Building Permit May 15,201(1 u „ _ I Department use only City of Northampton Status of Permit: rE1 cr asarrerscnoms Building Department Curb Cut/Driveway Permit ri—�r,,=rca�iae�,n 212 Main Street Sewer/Septlt:Availability Room 100 Wells~Availability Northampton, MA 01060 Two Ser"dF$4lictural Plans phone 413-587-1240 Fax 413-587-1272 PlovSite Panel- Other asOther Specify APPLICATION 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 63 Maple Street. Florence, MA 01062 Map t273^ Lot O(9 / Unit Zone Overlay District Elm St District Ca District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Re ord: 63 Maple St LLC. C/O Scott Keller 35 Main St Florence Name(Print) Current Mailing Address: 413-586-8600 Signature 14 L- Gr Telephone 2.2 Authorized Agent: Keiter Builders,Inc. 35 Main St Florence, MA 01062 Name(Print) Current Mailing Atltlress: ��/nGJC 413-586-8600 Signature ra P^'iAeot, Kill Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by perrind applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee y' 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2 +3+4+5) Check Number 63 This Section For Official Use Only Building Permit Number Date Issued Signatur ApatrCordmissionsibinio Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations [-1 Existing Wall Signs ❑ Demolition❑✓ Repairs El Additions E] Accessory Building[I Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Rooting❑ Change of Use❑ Other❑ Brief Description Demolition of interior commerical space to prepare for office renovation. 1� / 1 Of Proposed Work: fiCbl S -Il"tzi IV✓n-� SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly O A-1 A-2 0 A-3 ® 1A A-4 A-5 1B B Business 2A E Educational 2B F Factory 13 F-1 Q F-2 CE 2C H High Hazard ® 3A I Institutional 0 -1 1-2 ❑O 1-3 0 3B M Mercantile ® 4 R Residential R-1 Q R-2 R-3 Q 5A S Storage S-1 S-2 O 5B U Utility Specify: M Mixed Use Specify: S Special Use 0 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) I St 2nd 2n V 3,a 411, 4t Total Area(sf) Total Proposed New Construction(sf) Total Height(fl) Total Height ft 7.Water Supply(M.G.L. c.40,Q 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public Private Zone Outside Flood Zone Municipal On site disposal systeri Version 1.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning In,cot m..m be nurd in br Budding Dcvvmm�a Lot Size Frontage Setbacks Front Side I.: R: L:___R: Rc_r Building Height Bldg.Square Foolage % Open Space Footage % flea area minuv bldg&paved parkin-) N of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? ND Q DONT KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT 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 Q 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 acni 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 15,200(1 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 11 Name(Registrant): Registration Number Address Expiration Date See anachM control too 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 Keifer Builders, Inc Not Applicable El Company Name'. Scott Keifer Responsible In Charge of Construction 35 Main St. Florence, MA 01062 ess 413-586-8600 Pmsidenl_KBI Signature Telephone Version 1 .7 Commercial Building Permit May I>,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION I/ -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Scott Keiter,Owner 63 Maple St LLC 1. as Owner of the subject property Keller Builders, Inc. hereby authorize to ac[ my behalf,in all matters relative to work authorized by this building permit application. P.� G, S nature or owner Dale Keller Builders, Inc I. 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 Kei ter P¢rp Name_ jfj/�-'tom- /�e I'n.idcnt, tint 4.20.1$ Signature of Owner/Agent Data SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Suoervlsip Not Applicable ❑ Scott Keller CS-102457 Name of License Holder License Number 51 A Hatheld Street Northampton,MA 01062 06/20/2018 A ess Expiration Date hraih4mL sill 413-586-8600 Signature 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 Q No 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: 63 Maple st The debris will be transported by: Keiter Builders, Inc. The debris will be received by: valley Recycling Building permit number: Name of Permit Applicant Keiter Builder, Inc 120.18 j 45e— Pr,,idem, KRI U Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information Please Print Legibly Hanle(Business/Organization/Individuap: Keiter Builders, Inc. Address:35 Main Street City/State/Zip: Florence, MA 01062 phone #:413-586-8600 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 am a employer with 20 4. 0 1 am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. 0 New construction 2.0 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. ® Demolition working for me in any capacity. employees and have workers' 9. ® Building addition [No workers' comp. insurance comp. insurance.) required.] 5. 0 We are a corporation and its 10.® Electrical repairs or additions 3.® I m 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.] ' c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicam that checks bow pl must also till out the section below showing their workers compeisalme antics information. Huncemmers who submit this affidavit indicating they are doing all court,and then hire outside contractors must submit a new affidavit indicating such. Contractors that chock this box mut attached an additional sheet showing the name of the sub-contractors and state whether or not those entatic hm e employees_ Ifthesubaontractors have employees,they must provide their workers comp.policy number_ I am an emplover that is providing workers'compensation insurance for no,emplovees. Below is the policy and job site information. Insurance Company Name:AIM MUTUAL Policy#or Self-ins. Lic. #:WMZ80080071392017A Expiration Date: 6/1/18 — 63 Maple St Florence, MA Job Site Address: Clty/S[atel7.ip: 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. 1 do hereby mfi under the pains and penalties of perjury that the information provided above is true and correct. 4.20.18 Sy�atue' � President, KBI Dale' Phone #: 413586-8600 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#: ATE A`Rte® CERTIFICATE OF LIABILITY INSURANCE 06/29/2017 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(les)must be endorsed. N 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 CONEncT Cynthia Henderson, CISR Webber S Grinnell PHONE 1413)586-0111 IFAX pl gLslsa6-6ae1 8 North Ring Street EooBESS:chenderson@webberandgrinnell.com T INSURe 6 AFFORDINGCOVERIGE MAC I Northampton MA 01060 _ _ _ EBuRE�Select ive _ _ 119259 INSURED 6 RERBA.I.M. Mutual Reiter Builders, Inc. NsuRERC: Attn: Scott Reiter RMUMER B: 35 Main Street IMsuRER E'. F10Y9aCe MA 01062 1 INSURER F' COVERAGES CERTIFICATE NUMBER9laster map 2018 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. INDP TYPE OF INSURANCE AOL BUBP - - —pOLICYEFF—POLICYESP LEDPoLICV NUMBER Y ' Lens COMMERCMLGEHEMLHA&LI]Y EACH OCCURRENCE ib 1,000,000 - A L CLAIMs.MADE OPMAGETORENTEE $ OCCUR 300,000 I ' ', 53165867 � 6/1/306/l/20176/1/]OlB MERE ( nY one celwnl 5 5,000 _ _ PERSONALBADV INJURY IS_ 1,000,000 GEN L AGGREGATE LIMIT APPLES PER GENE RAL AGGREGATE $ 2.000,000 $ POLICY' PRP _ _ _ JECT LOC PROOUCTs.COMFIER AGO 6 2,000,000 iHER 8 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT IS 1,000,000 rvCHOWNED A91os11] 6/1/]011 _ , - A L ANY AUTO _ 180DILr INJURY(p PY- ) $ ALLOWNEO Ia 'AUTOS , - —- �Auros , Nuros 6n/zole aoD Lr u-- =N�ce lis $ HwED Auros AUTOS TYPE-1 PROPERTY DAMAGE 6_ 'MM ' s _ 5,000 $ I UMBRELLA HAD OCCUR EACH OCCURRENCE s 5-000,000 II EXCESS HAP A L I CLAIMS �GGREGATE a — D $ R TENTI NS 10,000 6216556] 6/1/2017 6/1/2018 8 WORKERS AMO EMPLOYE RS LIABILIITY NSATION Y/N' XT. TUTE R.9_R OFY PROPR ETOR/PARTNER/ EC nE L EAC CCIOE T S _110001000 CUA.E MBER ExcwOE N.,''N/a -- 'IMnlMolylnNN) WZ80080071392017A 6/11/201] SII 6/11/2018 EL OSEASE EA EMPLOYER S 1,000,000 DE CRUTION OF OLERATION5 Celox E DISEASE-PO(ICY HMIT S 11000,000 DESCRIPTION OF OPERATIONS/LOCATORS/VEHICLES IACORI.I A' AEEil 1 RvmMe 6che]ule,mey Ne amo.Uf mae sAAA......Xul CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE tf:::] 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 ACOR ,name and logo are registered marks of ACORD IN.G195mmenn