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30A-073 (5) BP-2022-0051 188 WARNER ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 30A-073-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0051 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS Contractor: License: Est. Cost: 80000 Scott KEITER 102457 Const.Class: Exp.Date:06/20/2022 Use Group: Owner: FREEDENFELD ROBIN B Lot Size (sq.ft.) Zoning: URB Applicant: KEITER CORPORATION - Applicant Address Phone: Insurance: 35 Main St. (413)586-8600 O MCC200200053820121A FLORENCE, MA 01062 ISSUED ON:01/20/2022 TO PERFORM THE FOLLOWING WORK: REPLACING WINDOWS TO ENTIRE HOME 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED I J A N 1 8 2022 The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code,780 CMRoF null DIN,INSPECTI CIPALITY AMP ION.�d.A0106i� USE Building Permit Application To Construct,Repair,Renovate OrDemolish a Revised Mar•2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:g ' ;/ Date Applied: 7.47, Building Official(Print Name) Signature to SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 188 WarnerStreet I.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Q Private 0 Zone: _ Outside Flood Zone? Check if yes® Municipal y On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP 2.1 Owner'of Record: Robin Freedenfeid Northampton, MA 01062 Name(Print) City,State.ZIP 188 Warner Street buttonstreetassoc@gmaii.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ® Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work: Replacing windows to entire home. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ 40 Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fee Check Nil Check Amount: ! Cash Amount: 6.Total Project Cost: $ 80,Q00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES • 5.1 Construction Supervisor License(CSL) CS-102457 6/20'22 Scott Keiter License Number Expiration Date Name of CSL Holder List CSL Type(see below) U +rear N No..and Street Type Description Florence, MA 01062 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1a:2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS \Window and Siding SF Solid Fuel Burning Appliances 413-586-8600 skeiter@ keiterbuilders,corn I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Keiter Builders, Inc. 761 4h8f2 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 35 Main Street skeiter@keiterbuilciers.com No.and Street Email address Florence,MA 01062 4.1 5P4641600 City/Town, State,ZIP Telephone SECTION 6: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 ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Keiter Corporation to act ga,my behalf,in all matters relative to work authorized by this building permit application. Robinn� Freedenfeld 4%22 Prinfbwner's Name(Electronic Signature) Date SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information co fined in this application is true and accurate to the best of my knowledge and understanding. President, KC 1/14/22 not Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov!oca Information on the Construction Supervisor License can be found at uww.mass.aovIdns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system - Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton I T era Massachusetts 1: *4 -: t, DEPARTMENT OF BUILDING INSPECTIONS „0) 212 Main Street • Municipal Building fsR^'" Northampton MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Valley Recycling The debris will be transported by: Name of Hauler: aiieyRecycling Signature of Applicant: ( '-0, �-C -P - Date: The Commonwealth of Massachusetts :. Department of Industrial Accidents l I Congress Street,Suite 100 • .= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Keiter Corporation Address: 35 Main Street City/State/Zip: io,ence MA C 1062 Phone#: 413-586-8600 Are you an employer?Check the appropriate box: Type of project(required): LOX 1 am a employer with 48 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in g 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance? ep 6.0 We are a corporation and its officers have exercised.their right of exemption per MGL c. 14. X❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showin g• o ipensation 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 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: AIM Mutual Policy#or Self-ins.Lic.#: tv1CC20020005382021 A Expiration Date: 6/11/2022 Job Site Address: 188 Warner Street City/State/Zip: 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce fy under the pains and penalties of perjury that the information provided above is true and correct 7 1 14'22 Signature: U ,,,- 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#: AC O® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/16/2021 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 Cyndie Henderson CISR,CPIA NAME: y Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 (A/C.No,Ext): (A/C,No): 8 North King Street E-MAIL chenderson@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: MA Employers/A.I.M. 12886 Keiter Corporation INSURER C: Attn:Scott Keiter INSURER D: 35 Main Street INSURER E Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2022 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RETED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 500,000 ___ MED EXP(Any one person) $ 15,000 A S2265567 06/01/2021 06/01/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105217 06/01/2021 06/01/2022 BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S2265567 06/01/2021 06/01/2022 AGGREGATE $ 5,000,000 DED X RETENTION $ 0 WORKERS COMPENSATION X STATUTE X ERH AND EMPLOYERS'LIABILITY Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA MCC20020005382021A 06/11/2021 06/11/2022 E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 ""Evidence of Insurance"" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A �� —D ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD