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Type: Partnership R.C.I. ROOFING MARK DELISLE 51 B HOLYOKE ST. c__,/,--44,.+4Q.Aul.•,_ EASTHAMPTON, MA 01027 Administrator • Qctw'rp7.. . a.o ti - (rz oaf i * r a trt( 1111 t ntt a � ti�.�a,: _ 447 �laasacansctb' � , • .... DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street • ' Municipal Building Northampton, Mass. 01060 .'Z.'�054 WORIcER'S COMPENSATION INSURANCE AFFIDAVIT I, - - • • 1 01 I•41 (liansc&Jpennimee) with a principal place of business/residence at: f . • - ib, - , • . �.- ....4_ _la ..■. • . „� . o�o� (phone #4?*113 ) 529tt- ? ?5 - . • . dty /staidnp) do hereby certify, under the pains and penalties of perjury, that (41I am an employer providing the following worker's compensation coverage for my employees working on this job: 1Jo.. o r o.\ v.:0,•.. 0 'F`, c'e. ins . Co . o C CI, . , Q i, ul A 3 tart 0 t o - s • o 9 - (Insurance Company) (Policy Number) (Expiration Date) ( ) 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company /Policy Number) (Expiration Date) (Name of Contractor) ' . (Insurance Company/Policy Number) (Expiration Date) • (Name of Contractor) (Insurance Company/Policy Number) ( Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (auactr additiosul shod if neoeuuy to i c ude loformseioo pertaining to all ooaa :tors) ( ) X am a sole proprietor and have no one w orking for me. ( ) 1 am a home owner performing all the work myself. . NOTE: pica= be ammo that whilo homoowocra wbo employ pasom to do maintenance, oxemuetioe•or repast wale co a of ;.o: noose than throe units in which the hoomovnacr resides or oa the ticuads apyuctenua donto are not geseeaity 000sidood to be cazptoy s uada the worker's oompcasatioo Act (GL1S2411(5)). application by a bomoowoee for a tiros ow pam&may rid=e==the Icgzi status of an employes ender to Woc oes Coaopoosation Ad. • I uadesstsod *at a copy *Mist eaatemeat may be forwarded to the Dega.Onom of loatatriai Amidst& Oho• of Immo hob• °wa* a vtxi5ossioo sad flat Wks to soars smogs vadaf section 2511. a(MOL 151 can lead to tbi irepoatiao dallied MOW oomisting dame me of up to SI,S00.00 attd/cr im mast prisod of tip to one yaw had eivt1 penalties is tba foam *fa Stop yak** sued a ' ' fine of 5100.00 *slay against roc. k ,lop.gr::›44!:: . For depattmaetal TL _ \ Permit :., • 'Signature of LiacusotJpermitttx Date �_� SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ ^] p . Name of License Holder : M QY h Tells 1 {.p , '77 License Number m. .. e. ..• 11. . II' 5 -a3 -l0 Address - Expiration Date Signature /.. Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ft.I. /Roo fing 126235 Company Name Registration Number S . _ S - Ob -10 H � a ` ora� `�`�� pt on t t1 // Expiration Date � 0kil l arnplh� / Ma. QIO73 Telephone& 3)52? -T7/ 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 cit No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 :is 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 attached . SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Replacement Windows Alteratlon(s) Roofing Ce Or Doors D • Accessory Bldg. ❑ Demolition ❑ - New Signs [G] Decks [E] Siding (Ell Other [p]' ` Brief Description of Proposed a�taCh� 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. Numbe• 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 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 1, �C�Y\�.. tt a �r , as Owner of the subject property `� '"� hereby authorize t Mar 1Jt°, I sl e o f ` 1 R • 3. -1+ . Rcc E ■n to act on my behalf, in all matters r lative to work authorized by thisbuilding permit application. 9 Attbc ip.ci 1 -ZB-to Signature'of Owner Date Y * - e - d o . I ,1 , 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 sle Prin 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 L,)t Size (� Frontage i Setbacks Front 4 C 1 Side L:! R: � L:'..� -. • R:1 . _ I -1 Rear ■ l __.. Building Height , t 1 1 _ . _I s — Bidg. Square Footage ( % i Open Space Footage (Lot area minus bldg & paved I parking) # 3f Parking Spaces ' 1 i Fill: (volume & Lpcation) I 11 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: I . IF YES: Was the permit recorded at the Registry of Deeds? NO 0 .. DONT KNOW 0 YES O IF YES: enter Book Pagel I and /or Document tit B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained Q , Date Issued: [ 1 C. Do any signs exist on the property? YES © 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 O NO O . IF YES, describe size, type and location: E. Will the construction activity disturb (Gearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO V IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton #' PF tY P Stattt��Ot Building Department Curb ��* 212 Main Street x * Sev+�r Room 100 Jt��'��( l , �, 1Net t • Northampton, MA 01060 $ 2 pt one 413 -587 -1240 Fax 413 -587 -1272 Plot/S 4- „, „ Other 'S 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 1 O 9 erc �'L S Map • Lot Unit �O (V■o� • Zone _ Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: `1�crclola. >� Dinr► v � 1 O1C' loci fw , /UcSr�1., �►'v� �� Name (Print) Current Mailing Ad s: a ttache 1 (4(3) (.1? - �s Telephone Signature 2.2 Authorized Agent: M al e / 1 k � ' I ed - q.e.z. _ • _ . • u Name (Print) J Current Mailing ddress: , CZ-1-3 ( 3) 527 - 4 1775 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Q fi 4 5 .... (0 Ob • 00 (a) Building Permit Fee 2. Electrical 1 L (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) $ 4( 0 00. O0 Check Number 1.551 This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date • 109 i 1; ' BP- 2010 -0749 GIS #: COMMONWEALTH OF MASSACHUSETTS % 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 -0749 Project # JS- 2010 - 001106 Est. Cost: $5600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 9713.88 Owner: TODRIN DIANE K Zoning: SC(8)/URC(92)/ Applicant: RCI ROOFING AT: 109 BRIDGE ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:2/23/2 01 0 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 2/23/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo