23B-066 MAR -07- 2012 04:19 From:RCI Roofing 4135278469 To:5871272 Page:2 /2
I .014 1.1°...cftwAftftlive4Ift erip
nooting Est Date
6 Line St.
Southampton, Ma. 01073 10/4/2011
Phone (473)527.4775
Fax (413) 527.8449
Name / Address Jab Location
Larysa Bacbinsky 7 Berkshire Terrace
7 Berkshire Terrace Florence, MA 01062
Florence, MA 01062 (413) 584 -3834
Terms Rep
Due on receipt Chris
Description Total
Remove existing slate roofs only. 4,800.00
Furnish & install 1/2" plywood over existing decking.
Furnish & install aluminum drip edge, pipe fleshings, chimney fleshings and step fleshings.
Furnish & install new lead counter fleshings.
Furnish & install ice & water barrier along eaves and valleys.
Furnish and install synthetic underlayment.
Furnish and install 30 year Tamko shingle.
Furnish and Install Tamito ridge vent.
MI exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers' specifications.
30 year Tamko material warranty included.
All related permits will be obtained by R.C.I. Roofing.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total 54,800.00
OF PAYMENT
5% Deposit
54b Deposit
Balance upon completion Customer Signature
Registration # 126235
Construction License # 074334 Date 6�
Insured by 1?anas & Fickert Ins.
(413) 527 -2700
;❑ The Commonwealth of Massachusetts
Department of Industrial /1ceielents
_ Office Of InresI1gt11ions
600 Washington Street
34. - = 7 B0510/1„11.4 021 I I
wwar, muss ovitlirr
\Yorkers' Compensation Insurance Affidavit: Builders /Contractors /hlectricians /P1ur lbers
Applicant Information Please Print Legibly
Name (Business organization /individual): �. ti!
Address
Phone "':
Are you an employer? Check the appropriate box: 1 Type of project (required):
1. ❑ "�I am a employer with _'. 4_ ❑ I am a gencrtl contractor and I b New construction
employees (full and/or part- tinae) '
have hired the sub-contractors
t listed on the aitat hcci sheet. I 7 � ] Remodeling
2. 1 I am a sole proprietor or partner-
ship and have no employees "These sub - contractors have S. ❑❑ Demolition
working for me in any capacity. workers comp. insurance. 9 (❑ 13uilding addition
No workers' comp. insurance S. L_ We are. a corporation and its t - 1
officers have exercised their 0..1 Electrical repairs or additions
required. ]
3. ❑ I am a homeowner doing all work right of exemption per MGL 11. 1 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4). and we have no 12.[il Roof repairs
insurance required.] t employees. [No workers'
l;
c•)nap. insurance required.] --
Any applicant that checks lti>x tr l trust also fin out the het<■w shmWi lieu « „r};ers et 1x11(5) inti .
t iunreowners who subtnil Ibis aftislnvil Illthettling they aie ,hint all 1(1(•1 sulnnit n new ailida511 indicut inp such
1 Contraclors that check this box must attached an additional sheet showing the liana' or the soh- cuitttactors and thee ws els' comp policy intOrlriat
I am an employer that is providing workers' compensation in.+rerancer for me employees. Below is the police' and job site
information.
Insurance Company Name
Policy # or Self -ins. Lie. #: � � i -; ' - - -- Expiration Date: : . t `”
Job Site Address: - - -�� e._<'!f .. t 1 r--rr. City /State /Zip:c\, bc ( U .Ok()I, Z
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 MGI_. c. 152 can lead to the imposition ofcriminal per of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties ill 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 nay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjure' that the information provided above is true and correct.
Sir nature: _i — , _ - -. Date: - - c'. -12_
Phone #: ( `11 > ` IZI57 �ei l •
•
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):
I. Board of Health 2. Building Department 3. Cityri'own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _,� Phone #: �t
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1 pp pp
Not Applicable ❑
Name of License Holder : Mark - Del I s l e. j '7 3 3
License Number
51B Hot St.- Easth Ma. oioa.1 5 - 03 - 42
Address Expiration Date
....l
Signature T elephon e
9. Registered Home Improvement Contractor: Not Applicable ❑
f C. I. ' Roof ; r _ 126235
Company Name Registration Number
51 B }lolyoke Street - P.O. Box 30'f 5 - Ob - 12
Address [� t� �f Expiration Date
Eastharnpron Ma. Dial? TelephonEen 4715
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 ❑ No ❑
H. - Home Owner Exemption
The current exemption for "homeowners' was extended to include Owner - occupied Dwellings 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 acts
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 he, 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 he 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- Ior which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of l�mployers to
F,mployees for injuries not resulting in Death) of the Massachusetts General Laws Annotated. you may be liable lbr person(s)
you hire to perlbrm 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 _attad
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition I I Replacement Windows Alteration(s) Li Roofing
Or Doors El
Accessory Bldg. I Demolition F 1 New Signs [D] Decks [E Siding [D] Other [D]
Brief Description of Proposed .
Work: • / ° A ►,
Alteration of existing bedroom Yes No ... ng new bedroom Yes No
Attached Narrative R 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
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 Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , L. cX k c2 Ra.( rN.t f��� , as Owner of the subject
property ^�
• hereby authorize V "► ar) ,(,Je, i S >. of P• C. I . Roof i nq
to act on my behalf, in all matters r lative to work authorized by th uilding permit application. J
a ttached 3 _Z -��
Signature of Owner Date
I, y . - i s ' • ,! . as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing ...lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
i li sl
Print Name
Signature of Owner /Agent Date
_ w
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
t'zisting Proposed Required by Zoning
This column to be tilled in by
Building Department
Lot Size
frontage
Setbacks Front
Side L: R: 1.: R:
Rear
Building I leight
Bldg. Square Footage 0„6
Open Space Footage
Lot area minus bldg & paved
parking)
4 of Parking Spaces
Fill:
(volume & 1.pcation)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW O YES 0
IF YES: enter Book Page and /or Document #
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 Obtained O , Date Issued:
C. Do any signs exist on the property? YES 0 NO O
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 Q
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
RECEIVE
2012 Department use only
' ? it of Northampton Status of Permit:
uilding Department Curb Cut /Driveway Permit
DE NORTHAMP frON, MA 01060 NS
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
—' 6 e.... V. '\-: ,re. \Lrc Map Lot Unit
c p Cr-1 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: p, ` ,
L O.. c�.50. L O,C_. \ �S Y.� 1 '.�cY, v, s-e, \ e. c t. . Cbcer7CG , Ma , Ol•
Name (Print) Current Mailing Address:
atta die CI Telephone
Signature
2.2 Authorized Agent:
.MaYlk e I — q.C.I, oof ;n 6 L.,.% pe5-E :4011 'Jiampton Na ._
Name (Print) y Current Mailing Address: 01013_
..--` -- (ii i3) 521- 47/5
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1 . Building ftoofir 4 j t Q O0. Cy' (a) Building Permit Fee
o
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) $ Li 2 00, ) Check Number / 7(e 35---- This Section For Official Use Only K
Building Permit Number:
Date
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
7 BERKSHIRE TER BP- 2012 -0768
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 066 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- 2012 -0768
Project # JS- 2012- 001350
Est. Cost: $4800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 19906.92 Owner: BACHINSKY LARYSA C
Zoning: URB(100)/ Applicant: RCI ROOFING
AT: 7 BERKSHIRE TER
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:3/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & PLY SLATE 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 3/7/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner