17A-014 (2) . Roofing Date
Y
Estimate
Southampton, Ma. 01073 3/14/2012
Phone (413) 527 -4775
Fax (413) 527 -8469
Name / Address Job Location
Jason Kulp 14 Hasting His.
14 Flasting Hts. Florence, Ma. ( 1062
Florence, Ma. 01062
Terms Rep
Estimate valid For 30 days Dave
Description Total
Remove existing roofs. 10,800.00
Furnish & install aluminum drip edge, pipe flashings, chimney II ishings and step (lashings.
Furnish & install new lead counter !lashings.
Furnish & install CertainTeed Winterguard ice & water harrier 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.
30 year CertainTeed material warranty included.
All related permits will he obtained by R.C.I. Roofing.
Add $2.50 per sq. IL for wood replacement if needed.
Add: $1,350.00 for Certainteed Landmark 50 year premium shingle.
A Certainteed Surestart Plus extended warranty will he included with a fee of $540.00 absorbed
by RCI Roofing if signed within 7 days. This extended warranty means that 20 of the 30 year
warranty is covered for labor and material. The mist 10 years of 31) year Certainteed warranty
would he covered for material only.
WE LOOK FORWARD f0 RUING BUSINESS WITH YOU.
Total $10,800.00
TERMS OF PAYMENT r�
5(h Deposit
—
Balance upon completion Customer Signature
Registration (1 1 26235
Construction License t# 074334 Dat ^�
e -� /' 1 /—
Insured by Banas & Fickert Ins.
(413) 527 -2700
The Commonwealth of Massachusetts
Deportment qf Industrial Accidents
'" Office of Investigations
600 Washington Street
1 6.4147;
Boston, i1 - l4 02111
w{t')t'.1n11ss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organizationfindividual). ,'�'�
Address: '.;, 1__,
City /State /Zip :„...y , Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
l
4. ❑ I ant a genera contractor and I
1.14 am a employer with _ -_ general G, [i New construction
have hired the sub - contractors
employees (full and/or part-time). 1: 7. I Remodeling
2. j ] I am a sole proprietor or partner- listed on the atta jied sheet_ f
ship and have no employees These sub- contractors have 8. ( Demolition
working for me in any capacity. workers comp. insurance. 9 I Building addition
[No workers' comp. insurance 5. Li We are a corporation and its • t
required.]
officers have exercised their 10.�_ 1 lecuical repairs or additions
3. [� I am a homeowner doing all work right of exemption per MGL 1 1 -❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, 1(4), and we have no 12 - Roo f repairs
insurance required.] 1 employees. [No workers'
13._j Other
comp. insurance required_]
"Any applicant that checks box tJ 1 must also fill out the section below showing their workers' compensation policy infurnution.
Homeowners who submit this affidavit indicating they are doing all wor and then hire outside contractors must submit a new uliidetvit indict; ing such.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy inforrnat ion
-
I am an employer that is providing workers' compensation insurance for my employees. Below is the police and jolt site
information..
Insurance Company Name: 'a\
Policy # or Self -ins. Lic. # \,„'i ,; wa Expiration iration Date : t
Job Site Address: N I A _ _ City /State. /Z_ip: 6 - (f (1'\
Attach a copy of the workers' corn - Insation policy declaration page (showing the policy number and expir anion 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 pains and penalties of perjury that the information provided above is true and correct.
Signature: c Date: —/
c
Phone #: 1; t (_ , LC( --
Official use only. Do not write in this area, to he completed by city or town official.
City or Town: - Permit /License # -_ I
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 #: _
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: p Not Applicable ❑ a
Name of License Holder: Mark "Del i s -I -el.- ------- . - - - -- '7'7 ` 334
4
License Number
5) 6 Hol St.- Easthampion / Ma. o loaf/ y5 - 03 -
Address Expiration Date
...l
(i3) 57- X1775
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
ftLI. 'Roo fnc__.._ 16235
Company Name Registration Number
5 (s }lolyoke Street - P.O. Box 309 5- 06-14 _
Address Expiration Date
Easthampton, Ma 1 O1 oa7 Telephone 1 3)527
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 6? No ❑
1.1. — Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one ( I) 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. CM R 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 Tamil■ dwcllinu. 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 fur which this permit is issued.
Also be advised that with reference to Chapter I52 (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 liable for person(s)
you hire to pertOrm work for you under this permit.
1 he undersigned "homeowner certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances. State and Local 1..oninu Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature attaahe.8
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition Replacement Windows Alteration(s) n Roofing riif
Or Doors ❑
Accessory Bldg. I Demolition New Signs [D] Decks [C] Siding [D] Other [0]
Brief Description of Proposed at h J
Work: L r e.
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
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, Q- '(\ , as Owner of the subject
property JY1 hereby authorize a � e�1 sl Q Q C f I • C. I . Roof, n
to act on my behalf, in all matters relative to work authorized by this uilding permit application. 9
attaehe�l z (.► -[
Signature of Owner Date
I J IaY 1 "D el i sl e, -a S - au thor17 ez aci ` , 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.
Vert
Prin
5 12,( 4 - ) a,
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
I:xisling Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: I,: R:
Rear
I uildinr I leicht
Hldg. Square Footage "h
Open Space Footage
(Lot area minus bldg \ paved
parking)
i' of Parking Spaces — - —
Fill:
(volume K dpcalion)
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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained O , Date Issued:
C. Do any signs exist on the property? YES O 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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED Department use only
City of Northampton Status of Permit:
I MY 3 !Se Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
DEPT. OF Bu;L rEcrloNs Room 100 Water/Well Availability
NOR- HAW'r v -AA 01060
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
I k S te: V,VS Map Lot Unit
�^� �� Zone Overlay District
t� Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
K ' ` S • - 'cab( ma -
Name (Print) Cur ( e�1n a2 g Address: O1Ub2-
a tta eh e d Telephone 3
Signature
2.2 Authorized Agent:
Name ( I)e le, - t�.C.I. oof; n� 1��� SDu amptor, .Ma.
Name (Print) J Current Mailing Address: 0101.3_
(q13) 521- 4? 15
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Roofin /c) 13 3 • °® (a) Building Permit Fee —
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) '$ f () 1 00 Check Number '2 g tag' O 3 S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
14 HASTINGS HGTS BP- 2012 -1058
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 014 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 -1058
Project # JS- 2012 - 001827
Est. Cost: $10800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 13503.60 Owner: KULP JASON M & MOHINI S KULP
Zoning: RI(100)/URA(100)/WSP(14)/ Applicant: RCI ROOFING
AT: 14 HASTINGS HGTS
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMAO1073 ISSUED ON:5/31/2012 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 5/31/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
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