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