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31B KEITER BUILDERS35 Main Street-Florence-MA-01062-Phone:413-586-8600-Fax:413-280-0124-keiterbuilders.com Commissioner Hasbrouck 11.1.18 Subject: Request for Waiver | request that you grant a modification to waive the requirement for control construction for the Smith College Henshaw[ Roof Project atI@HenshavvAveinNortharnptonbecause1hexxorkioofanninornature, vviUnot affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost uf control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of7Q0 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Respectfully, dcScotttKeiter KeiterBui|ders, Inc. 35Main 5t Florence, K8AD10O2 ACC)RO CERTIFICATE OF LIABILITY INSURANCE DATE A E(Mi7�DDN 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 Cynthia Henderson CISR Elite NAME: Webber&Grinnell PHONE (413}586-0111 FAX Ne: (413)586-6481 C No Eat 8 North King StreetADDRess: chenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina INSURED INSURER B: A.I.M.Mutual/A.I.M, Keiter Builders,Inc. INSURER C: Attn:Scott Keller INSURER D: 35 Main Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2019 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 CONTRACTOR 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. iLTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD EFF MM/DD POLICY P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE a OCCUR PREMISES Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A S2265567 06/01/2018 06/01/2019 -PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIESPER: GENERAL AGGREGATE $ 2.000,000 POLICY ❑jECOT- FILOG PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accMenY _ ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED A9105217 06/01/2018 06/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per accident Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5'000,000 A EXCESSL�/IAB HCLAIMS-MADE S2265567 06101/2016 06/01/2019 AGGREGATE $ 5.000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY �+' STATUTE X ER_ YIN 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ B OFFICER/MEMBEREXCLUDED? a NIA MCC20020005382018A 06/11/2016 06!11(2019 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2011 v www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizationAndividual): 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 I am a employer with 20 4. ® 1 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' [No workers' comp, insurance comp. insurance.$ 9 ® Building addition required.] 5. ® We are a corporation and its 10.® 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.[R Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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. AIM MUTUAL Insurance Company Name: Policy#or Self-ins. Lic. #: MCC20020005382018A Expiration Date:6/11/19 Job Site Address: 18 Henshaw Ave City/State/Zip: Northampton, 0106( 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 rtif, under the pains and penalties of perjury that the information provided above is true and correct. 10.26.18 Simature. President,KSI Date: Phone#: 413-586-8600 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#: I 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: 18 Henshaw Ave Unit C 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 10.26.18 zt- ;4;e President,KH1 Date Signature of Permit Applicant Version 1.7 Commercial Building Peradt May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(730 CMR 110.11) Independent Structural Engineeft Structural Peer Review Required Yes 0 No • SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT l G3fy Hartwell as Owner of the subject property Keiter B rs,Inc. hereby authorize to act on my behalf,In all all ative to work ay this building permit application. 10129/18 Signature of Owner Qat 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 e I!M✓ tn.t..Ei-� d�'! 10.26.18 SignMurs of OwnedA wnj Date SECTION 12-CONSTRUCTION SERVICES 100 Licensed Construction Supervisor: Not Applicable d Scott Keiter CS-102457 Name of License Holder License Number SIA Hatheld Street 6/20/20 Expiration Date 413-586-8600 d4mature 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 buildim Permit. Signed Affidavit Attached Yes * No Versionl.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 13 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 Keiter Builders,Inc Not Applicable E Company Name: Scott Keiter Responsible In Charge of Construction 35 Main St.Florence,MA 0 1 U62 Aftess Pt I-,.-,, President,KEII 413-586-8600 Signature Telephone Version lJCommercial Building Permit May 15.2O0O 8. NORTHAMPTON ZON& —] Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area rninus bldg&paved #of Parking Spaces A. Has a Special Permit/Vartance/Finding ever been issued for/on the site? NO \ J DONTNNOVV YES 0 IF YES, date issued: IF YES: Was the permit recorded aLthe Registry ofDeeds? �� �� �� �� NNODDN7KNO� �� YES �� IF YES: enter Book Page and/or Document# �� �� B. Does the site contain a brook, body ofwater orwetlands? NO V�� DONT KNOW \.� YES \`� IFYES, has apermit been orneed tobcobtained from the Conservation Commission? Needs tmbeobtained /—\ Obtained /—\�/� Date\../ ' ' C. Doany signs exist onthe pnoperty ��� YES \~~/ NO |FYES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,orfilling)over 1acre oriaitpart ofacommon plan that will disturb over 1acre? YEG � l NO �W�l �� \M/ 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 I Interior Alterations 0 Existing Wall Signs 0 Demolition El Repairs El Additions El Accessory Building 0 Exterior Alteration 0 Existing Ground Sign El New Signs El Roofing❑✓ Change of Use❑ Other El Brief Description New roofing and rot repair Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 LoJ A-2 (9 A-3 1A Fol A-4 A-5 no 1B 70 B Business 2A Fol E Educational 2B F Factory 01 F-1 TM F-2 2C H High Hazard 0 3A Fa I Institutional M 1-1 ro 1-2 93 1-3 93 3B Q M Mercantile 0 4 ro R Residential fa R-1 93 R-2 R-3 93 5A on S Storage fQ S-1 0 S-2 93 5B 70 U utility n Specify: M Mixed Use Fol Specify: S Special Use 93 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 I BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st ist 2"d 2"d 3rd 3`d 4 th 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 q Private (q I Zone Outside Flood ZoneEj Municipal q On site disposal systemo ,� F ��. _ RJCZF— Version 1.7 Commercial Budding Pennit May 15,2000 Dep®rtrneM use Dray► City of Northampton Status at permit: , Building Department CA Cul/Driveway Perna _ 212 Main Street Room 100 ` Wia,�scf W�etl�4vaNabltjty'� � ' Northampton, MA 01060 •4 Is ofg "ns phone phone 413-587-1240 Fax 413-587-1272 Pwvsits Plans Othet�spedfy APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION i-SITE INFORMATION 1.1 P ; -- Thts section to be completed by office A 8 ens aw Ave(Unit Q ap 316 Lot 1q? Unit FOVm — 2 2018 !0" 1 Overlay District PT OF Sull 121 - MPFm District CB District SECTION 2-PROPERTY OW NE T 1060 2.1 Owner of R92ord: The Truste /Mnagement he Smith College Name(Print)C/o FaClli , Current Melling Address: 1 126 West St, Northampton, MA 01063 Signature Tel 413-585-244 2.2 Authorized Aaent• Keiter 13tnlder ,lnc. 35 Main Street rlorence,MA U 1 U62 Name(Print) Currant MaulAddress: 413-58,T-8600 Signature Telephone $teCTION 3-ESTIMATED CONSTR tr'TION COSTS Item Estimated Cost(Dollars)to be Official Use Only --completed by Dermilt applicant 1. Building li J (a)Building Permit Fee 2. Electrical / (b)Estimated Total Cost of Construction from 6 3. Plumbing / Building Permit Fee 4. Mechanical(HVAC) 0O. 5.Fire Protection 6. Total=0 +2+3+4+5 or" Check Number This Section For Official Use Only Building Permit Number Date Issued signature: l Building Commilasionedinspedor of Buildings Date 18 HENSHAW AVE UNIT C BP-2019-0550 GIS#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 3 1 B- 197 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2019-0550 Project# JS-2019-000893 Est.Cost:$12000.00 Fee:$100.QO PERMISSION IS HEREBY GRANTED TO: ConLt.Class: Contractor: License: Use Groo: KEITER BUILDERS 102457 Lot Size(sg.ft.): 7274.52 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning:EU(100)/URC(100)/ Anplicant.- KEITER BUILDERS AT. 18 HENSHAW AVE UNIT C Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 Q WC FLORENCEMA01062 ISSUED ON.-111612018 0:00.00 TO PERFORM THE FOLLOWING WORK.-NEW ROOFING AND ROT REPAIR 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 RepgEl!pent Fireplace/Chimney: Rough: M 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: FeeTyipe: Date Paid: Amount: Building 11/6/2018 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner