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17A-115 Roofing 6 Line St. P hone (4113) 52 7- 47 77073 5 Estimate Date Phone (43) 7 -7 Fax (413) 527 -8469 8/25/2009 Name / Address Job Location CONSTRUCT ASSOCIATES ATTN: Steven Ross 14 Claire Ave. 36 Service Center Road Florence, Ma. 01062 Northampton, MA 01060 (413) 584 -1224 Terms Rep Due on receipt Chris Job Description Total Remove existing roofs. 8,800.00 Furnish & install aluminum drip edge, pipe flashings, chimney flashings and step (lashings. Furnish & install new lead counter flashings. Furnish & install CertainTeed Winterguard ice & water barrier along eaves and valleys. Furnish and install synthetic underlayment over existing deck. Furnish and install 30 year CertainTeed Woodscape Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be performed according to manufacturers' specifications. 5 -year RCI Roofing workmanship warranty included. 30 year CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. SPECIAL ITEMS NEEDED Add $2.50 per sq. ft. for wood decking replacement if needed. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $8,800.00 TERMS OF PAYMENT 5% Deposit Balance upon completion Customer Signature Registration # 126235 Construction License # 074334 Date Insured by Reynolds, Barnes & Hebb, Inc. 413 - 447 -7376 Alow ' , 7 ' . ea il k gite mmoltwea&A ortAadaoltudea3 Board of Building Regulations and Standards - - _, 4 , Construction Supervisor License if License, CS 74334 IS4pWn ' 01 0 Tr# 23520 01. :-/- i ' • MARK T DELISLE 33 FIRST AVE EASTHAMPTON, MA MA 01027 Commissioner L , , 1 , ,..---- qk iowvotolutsea&i of,/iamaduatmla - Board of Building Regulations and Standards 1 * .ii e ' l HOME IMPROVEMENT CONTRACTOR C. --- e 11 i Registration: 126235 Expiration: 5/6/2010 Tr# 266063 1 • Type: Partnership R.C.I. ROOFING MARK DELISLE 51 B HOLYOKE ST. EASTHAMPTON, MA 01027 Administrator e The Commonwealth of Massachusetts ..� Department of Industrial Accidents = fr Office of Investigations 600 Washington Street '— Boston, MA 02111 mo w. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): TV c 1 \AS Address: �,� \AC._ City /State /Zip: , n �1. o Phone #013) 541- LI `l 15 Are you an employer? Check the appropriate box: Type of project (required): 1.21 I am a employer with 20 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. ❑ New construction 2. (i 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' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance p required.] ' 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. n 1 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.M Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.121 Other comp. insurance required.] *Any 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. 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: O....Qt. VONr-.)c . Policy # or Self -ins. Lic. #: AAAjt LtA 5 p`1 35 (p, Expiration Date: / 0 - 0 1 0 Job Site Address: iq 60,1 cC. Owe,. City /State /Zip: t)o t 0 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 certify under the , ins and penalties of perjury that the information provided above is true and correct Signature: Date: Z L.- (Q ' 0 1 Phone #: — L171,`15 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 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: +�) 1 )e Not Applicable ❑ • Name of License Holder: 7'1ay� lide, [ ca 43311 License Number 5+ 0 _ • •. 4 1 .� u . • • 5 —O 3 - Address Expiration Date • Signature Telephone 9. Reoistere i Home Improvement Contractor: Not Applicable ❑ fte. i.'o f r 126235 Company Name • Registration Number " 5 -06 -10 Aaoreaa '� — - C ^A �/n Expiration Date t�►` narnptcrt M a . 01 613 Telephon4ii 3)5,27. t1 '! ,5 SECTION 10- 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 ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwelllinas of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner sett as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is. or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be, required from time to time, during and upon completion of the work•for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, YOU may be _Able for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. • Homeowner Signature attached i 2 t' a ?� ;� - • • • -, SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing W Or Doors 0 . • Accessory Bldg. ❑ Demolition ❑ - New Signs [0] Decks . [D Siding [DJ Other (P' ' Brief Description of Proposed at LaC��"1.P11 Work: L Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet .6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms , y. c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tan< City Sewer •. Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C saw. -- .F4bC . , as Owner of the subject property Q . hereby authorize JV1 - bel l RI e d f ] • 0.1 . ROOT' t R to act on my behalf, in all matters r ative to work authorized by this uilding permit application. . t •I I tp - 0 Sigh e`of Owner Date ' I • - • .. , / , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing . • s lication are true and accurate, to the best of my knowledge and belief. • Signed under the pains and penalties of perjury. aYk I; Al'e∎ ....4e Print Name . . it - G e9 Signature of Owner /Agent Date • Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size r ...... Frontage Setbacks Front Side L:1. 1 R: .._ _1 L:�-.�.__ R:[ __._..I C J C Rear I 1 1. _.. ._.± = Building Height -- - Bldg. Square Footage 1% - Open Space Footage (Lot area minus bldg & paved J i I _.._. 1 1 .. + 1 N. 1 parking) # of Parking Spaces I - I ( LTA Fill: (volume & Lpcation) 1 .._. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:L II . • " . • IF YES: Was the permit recorded at the Registry of Deeds? NO 0 .. DONT KNOW 0 YES 0 IF YES: enter Book 1 Page[ j and /or Document #I 1 B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: I C. Do any signs exist on the property? YES © NO O IF YES, describe size, type and location: . I D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0 IF YES, describe size, type and location: I E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or Is it pad of a common pian • that will disturb over 1 acre? YES O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1 ', 4 , 4 ' ' - ),., 4 C, kid • • - City of Northampton Status 'of Peittl�� B uilding Department Curb cuvioO ie+ z 0.1 212 Main Street et Room 100 Vyate Nell A�+ I s -Fk� uw .CY+ y .psi q - MA 01060 1*j $ets$cf g w � phone 413 =587 -1240 Fax 413- 587 -1272 �lotlt i�1a11 e r�F O Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAM,ti_Y DWELLI, SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be compiet• office q � (`�, a—\) e. Map Lot Unit S23 AQA • Zone Overlay Distric . Elm St. District CB Dis SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT l 2.1 Owner of Record; , AS 04SS(C St- ►cx. L' stz :f\ -tx ;1, ,- 1ar,.,-, 11s4 Name (Print) }} __ Curr nt Mailing Address: 01•540 a �.aCte� `i ts) �58l 1ZZy Telep one Signature - 2.2 Authorized Agent: Name (P 9 Current Mailing Address: ( 521 - 4775 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use On completed by permit applicant 1. Building Roofi 4 �, ''0 0 • 00 (a) Building Permit Fee 2. Electrical 7 (b) Estimated Total Cost of Construction torn (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4+5) $ . i . ? Check Number /� L This Section For Official Use Only Date Building Permit Number. Issued: • Signature: D Building Commissioner /Inspector of Buildings ;;� J r A w :AV' BP- 2010 -0511 GIS #: COMMONWEALTH OF MASSACHUSETTS twakoc, t7A i t CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0511 Project # JS- 2010- 000715 Est. Cost: $8800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 9016.92 Owner: STEPHEN D ROSS Zoning: URA(100) / /R1 Applicant: RCI ROOFING AT: 14 CLAIRE AVE Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON :11/9/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE ROOF 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 11/9/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo