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31D-020 (62) SCOTT GYM- 102 LOWER COLLEGE LANE BP-2020-0986 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31 D-020 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2020-0986 Proiect# JS-2020-001668 Est.Cost: $19000.00 Fee:$133.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KEITER BUILDERS 102457 Lot Size(sq.ft.): 479160.00 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(98)/URC(85)/RR(28)/WP(27)/FFR(16)/ Applicant. KEITER BUILDERS AT: SCOTT GYM - 102 LOWER COLLEGE LANE Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 WC FLORENCEMA01062 ISSUED ON:3/9/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIRS TO STAIRS 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 3/9/2020 0:00:00 $133.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Version l.7 Commercial Building Permit May 15,2000 i v Department use only 0 0 rn City of Northampton Status of Permit: T ::0 Building Department Curb Cut/Driveway Permit rn 212 Main Street Sewer/Septic Availability OZ W Room 100 WaterfWell Availability b N Northampton, MA 01060 Two Sets of Structural Plans p A13-587-1240 Fax 413-587-1272 Plot/Site Plans_ u Other Specify. APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATIONP4`�� 1.1 Property Address: This section to be completed by office 102 Lower College Lane Map 31 ✓ Lot CPl'd Unit S C o�A G�n Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name a (Print)) �Fd,,; r � Cs !fi `�ti>, rly "Z` _ Current Mailing Address 1 r' � %7'.c-'L'7' Signature Telep hone 22 Authorized Ascent: Kelter Builders, Inc. 3.) Main Street 11orence, MA U IU02 Name(Print) Current Mailing Address: 413-586-8600 Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION gO T$ Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Uco (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of T JJ Construction from 6 3. Plumbing Building Permit Fee r 4. Mechanical(HVAC) l �3 5. Fire Protection 6. Total =0 +2 +3+4 +.5) Check Number This Section For Official Use Only Building Permit Number Date Q/, 15SUed Signature: '"', 2 , ao Building ommissioner/Inspector of BuitAgs Date 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 Wail Signs ❑ Demolition❑ Repairs 2 Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description � t S ,` f S _ Of Proposed Work: N p' SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly In A-1 © A-2 [II A-3 KE 1A A4 [Q] A-5 © 1B B Business ® 2A 93 E Educational ® 2B 93 F Factory ® F-1 F-2 © 2C U H High Hazard ® 3A I Institutional ® 1-1 1-2 ® 1-3 1:11 3B M Mercantile ® 4 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) 1 sc 2 2"d nd 3'° 3'd 4"' 4u, Total Area(sf) Total Proposed New Construction(so 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 9 Private g I Zone Outside Flood Zoned Municipal ® On site disposal system[ Version 13 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 arra 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 0 DONT KNOW � YES a IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES a 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 a YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, 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,or filling)over 1 acre or Is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 Reglstered Architect: Not Applicable O 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 Dale Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Keiter Builders,Inc Not Applicable m Company Name: Scott Keiter Responsible In Charge of Construction 35 Main St. Florence,MA U 1062 X 413-586-86UU Prssidcnt,tCBt Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. lir /i Ua7�'�'`� F jam" `5'`>� � "` ,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 pate Keiter Builders,Inc I, _ ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing applicat on are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Scott Keiter Priv! e 03.03.2020 Sign urs of Owner/Agent date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Su ervlsor: Not Applicable ❑ Scott Keiter CS-102457 Name of License Holder: License Number 51 A Hatheld Street 6/20/20 Ad ss ExpiraUon Data && 413-586-8600 nature 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 e No 0 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: 102 Lower College lane The debris will be transported by: Keiter Builders, Inc. The debris will be received by: valley Recycling / USA waste Building permit number: Name of Permit Applicant Keiter Builder Inc 03.03.2020 � Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of IndustrialAccidents ' 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 Mame (Bu-siness/Organization/individual): Keifer 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): LS I am a employer with 22 4. ® I am a general contractor and 1 b. []New construction employees (full and/or part-time)." have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. S Remodeling ship and have no employees These sub-contractors have g. ® 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 ® Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.® Other _ camp. 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employers. If the subcontractors 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 andjob site information. AIM MUTUAL Insurance Company Name: Policy#or Self--ins. Lic. #: MCC20020005382019A Expiration Date:6/11/2020 Joh Site Address: 102 Lower College Lane City/StatelLip:,Northampton 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 tine 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. Ido hereby rtify under the pains and penalties of perjury that the information provided above is true and correct. President,ICBI 2.25.2020 $irtatttrc. Dat e: 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/Ucense # Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: A'cC)I'Ra CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 0&0312019 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 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 CT C die Henderson CISR,CPIA NAME:: Webber 8 Grinnell PHONE (413)586-0111 AtC No: (413)586-6481 AM,09 8 North King Street L44NL chendersongrwebberandgrinneil.com -ADDRESS: INSURER(S)AFFORDING COVERAGE NA)C/ Northampton MA 01460 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B, At M MUbiaUAJ M. Keiter Builders,Inc. INSURER C: Attn:Scott Keller INSURER 0: 35 Main Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER. Master Exp 2020 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 LTR TYPE OF INSURANCE 1A"Mk POLICY NUMBER Mwt) MWDINYYYY LIMITS COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE ®OCCUR PREMISES Ea xarrence f 500,000 MED EXP(Any one person) S 15,440 A 52265567 N/01t2019 06101r2020 1,o0o,000 PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LtMrT APPLIES PER. GENERAL AGGREGATE $ 2.000,000 POLICY 0 PES ❑LOC PRODUCTS•COMPIOP AGG S 2.000,000 OTHER $ AUTOMOBILE L4IEILITY COMSINED SINGLE LIMIT S 1,000,000 Ea ac odentl ANY AUTO BODILY INJURY IPer Perin) f A OWNED SCHEDULED A9105217 0610112019 06101/2020 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED �/ NON-OWNED PROPERTY AMA AUTOS ONLY X AUTOS ONLY Per*CcideM z Medical payments f 5,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMS-MADE 52265567 06/01(2019 0610112020 AGGREGATE S 5.000,000 OED 1 RETENTION S 10'000 f WORKERS COMPENSATION x OTH- AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ..., _ ANY PROPRIETORIPARTNERIEXECtN� NIA MCC20020405382019A 46/11/2019 E.L ITNE .1,000.000 B OFFICERIMENBFREXCLUDED7 06/1112020 .EACH ACCIDENT z (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $ 1,000,000 If ym,daealbe uMer DESCRIPTION OF OPERATIONS below E.L.DISEASE-POL ICY LIMIT S 1,000,000 DESCRJPTI IN OF OPERAT)ONS I LOCATIONS I VEHICLES (ACORD 1 D1,Additional Ramarke Schedule,may be■Uached M morn epees Is mqulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Q 1985-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD KEITER BUILDERS35 Main Street•Florence-MA•01062•Phone:413-586-8600•Fax:413-280-0124•keiterbuilders com Commissioner Hasbrouck 03.03.2020 Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the Scott Gym Egress Remediation at 102 Lower College in Northampton because the work is of a 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. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Res ctfully, Sc t Kelter Biter Builders, Inc. 35 Main St Florence, MA 01062