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17A-209 (4)
RC.I. Roofin g 6 Line St. Estimate Date Southampton, Ma. 01073 8/8/2012 Phone (413) 527 -4775 Fax (413) 527 -8469 Name / Address Job Location Jack Doherty 119 North Maple St. 119 North Maple St. Florence, Ma. 01062 • Florence, Ma. 01062 (413) 584 -0143 Terms Rep Estimate valid for 30 days Dave Description Total Remove existing roofs. 2,200.00 Furnish and install 1/2" fiberboard insulation, mechanically fastened. Furnish and install 1/2" pressure treated wood nailer at perimeter. Furnish and install .060 TPO roof system, mechanically fastened. Furnish and install .032 aluminum edge metal. Furnish and install all related flashings. All work to be performed according to manufacturers' specifications. All exterior roofing related debris to be removed by R.C.I. Roofing. 5 -year R.C.I. workmanship warranty included. All related permits will be obtained by R.C.I. Roofing. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $2,200.00 TERMS OF PAYMENT 5% Deposit '� JG Balance upon completion Customer Si �, 4 ) -' Registration # 126235 Construction License # 074334 Date ) 0 ' Insured by Banas & Fickert Ins. (413) 527-2700 The Commonwealth of Massachusetts Department of Industrial Accidents .. • _ Office of Investigations • ; = 600 Washington Street y = u � C _ .s Boston, MA 02111 ye' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): R L,`Y., R pp U. e■s U.. S Address: C. L:, r. e.. 5\-- City /State /Zip: Sv`\ - �cv \i cN O'k a. o l 0 3 • Phone #: ( 52,1 - Y7 Are you an employer? Check the appropriate box: Type of project (required): 1. [gq am a employer with z O 4. 111 6, ❑ I am a general contractor and I * have hired the sub - contractors New construction employees (full and/or part- time). 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I 7 . n Remodeling ship and have no employees These sub - contractors have 8. ( Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We area corporation and its required.] officers have exercised their 10.n Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 1 I .fl P lumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. Rrcoof repairs insurance required.] t employees. [No workers' 13. O ther 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. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 0...cc "S , `� �rr..,r\Ls.,_ C Q--, , Policy # or Self-ins. Lic. #: 1, C v (o 3 y 0.5 Expiration Date: 1 U S - 1 2, Job Site Address: 11 Mor 1- flrk4 _ } • City /State /Zip:C tyrt yvAix. 61C)4 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 pains and penalties of perjury that the information provided above is true and correct. Signature: . (� —z-< Date: g Z 1— lit— Phone #: 013 :5 - 41 `t S • 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S 1 Not Applicable ❑0 3 ' .� Name of License Holder : M aY li "D° is J 1 e, 17 1 3 License Number 51E1 1-Hot St.- Easthmpton Ma. moat/ at/ 5-03 - j4 4 Address Expiration Date (413) 5 :/- i.1'7 1 75 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ fte.I. o f ri 9 126235 Company Name Registration Number 518 }101yoke Street - P. O. 60ox 309 5 - ob - $.y Address t1 Expiration Date Eastlhmpl} on M. Di 2. / n Telephon€H13)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 No ❑ 11. - 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 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 liable 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 Attaeheed • • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [CI Siding [❑] Other [❑] Brief Description of Proposed a}�}�anh� -U 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 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, (S\n , as Owner of the subject property hereby authorize ay "Del si P , of R. 3. I . Roof; n9 to act on my behalf, in all matters relative to work authorized by this 'building permit application. attached - 7- 1 - Vz Signature of Owner Date I, J4y e i Si e. ' aS a11 LhOYL xeA a 611t , as Owner /Authorized Agent hereby declare that the statements and information on the foregoinglication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Niar� iiSle Print Name 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 Frontage ' Setbacks Front Side L:' ' R: L: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Lpcation) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? ., NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW 0 YES Q IF YES: enter Book ! Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Date Issued: Do any signs exist on the property? YES 0 NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut /Driveway Permit AUG 212 Main Street Sewer/Septic Availability r ` 2012 / Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans , 13- 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 ?Jo MA-eke., - Map Lot Unit QUO re_ c.. 't •-,k • Zone Overlay District Elm St. District GB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: - -\0&,q 0\ 1 Pot , ort_nc.c tots Z_ Name (Print) Current Mailing Address: attached �y�3� ,may- 01'43 Telephone Signature 2.2 Authorized Agent: ,MaY1‘ 7e - le, - , .C.L Roofin _6 es-L .�"o arnpton, ,Ma. Name (Print) y Current Mailing Address: 0I©l �.- 0 I3) 521 - 4115 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 00 .F) 41 z a 00 aU (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) $ 'aa QV Check Number r-loOry is This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 119 NORTH MAPLE ST BP- 2013 -0204 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 209 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- 2013 -0204 Project # JS- 2013- 000335 Est. Cost: $2200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 44431.20 Owner: DOHERTY JOHN C Zoning: URB(83)/URA(17)/ Applicant: RCI ROOFING AT: 119 NORTH MAPLE ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:8/23/2012 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 8/23/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner