17D-058 (4) RC00 1 1 1 zoloft�
.1- Roofing Date
6 Line St.
Estimate
Southampton, Ma. 01073 5/8/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Kenny & Kathy,Sherman 15 Garfield Ave.
15 Garfield Ave. Florence, MA 01062
Florence, MA 01062 (413) 586-2176
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove 2 existing flat roofs. 3,500.00
Furnish and install 1/2" fiberboard insulation, mechanically fastened.
Furnish and install .060 reinforced rubber roof system.
Furnish and install all related flashings.
Furnish and install .032 aluminum drip edge.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work to be performed according to manufacturers'specifications.
5 year R.C.I. workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $3,500.00
TLRMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signatur
Registration# 126235
Construction License#074334 Date /� —/
` �
Insured by Banas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial`Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Iame (Business/OrganizationlIndividual): ,1g U..C�
address:
,ity/State/Zip:Sc,���-�G.,�,o no.- 0f o-7 3 Phone #: 13
re you an employer? Check the'approprlate box: Type of project (required):
am a employer with Z 0 4. ❑ I am a general contractor and I 6, ❑ New construction
employees (full and/or part:time).* have hired the sub-contractors
❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ 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 are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions
myself, [No workers' comp, c. 152, §1(4),,and we have no 12. Roof repairs
insurance required.] t employees. [No workers' 13.7 Other
comp, insurance required.]
iy applicant that checks box#I must also fill out the section below showing their workers'compensation policy information;
)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy information.
m an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
brmation.
uranee Company Name:
licy#or Self-ins. Lic, #:-W o5 Expiration Date: 10 S - t-}
Site Address; wn G �w�a r` City/State/Zip;,A(,�,rt_r T,t1LA�LabZ
tack a copy of the wor rs' compen tion policy declaration page (showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal per>.alties of a
.e 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
up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
to hereby certify under the pains and penalties of perjury that the information provided above is true and correc4
gnature: '�iz�' Date:
tone#: 3 5 Z,'(-�(`► `i
Official use only. Do not write lit 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 #c
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O ]
Name of License Holder: N�aY� ��;� S �p.� f 7 N 3 3'/j
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
'Roo£i rQ l 2b 235
Company Name Registrration Number
Aooreaa Expiration Date
. Ynntnyl. a. o 10 3 Telephon •J4 t
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....... 4z No...... ❑
11. - Home Owner Exemption
The current exemption for"hormeowners"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 shad 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.
,41so 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 persons)
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
\orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature At.aeb -d__
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs ) Decks [ Siding [p] Other[[J]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedro m 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
V_rf\,(;L tA as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
attaehad 5-I6 - ��{
Signature of Owner Date
I as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing aqpplication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
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 Departnient
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus b1cig&paved
4 of Parking Spaces
A. Has a Special Ponnit/Vahance/Finding ever been issued for/on the site? `
/��
�`�
NO v�/ DON'T KNOV� t_� YES
|
|F YES, date ioued; |
IF YES: Was the permit recorded at the Registry of Deeds?
NO �� DON'T �-t_�� YES �`\_/�
^~/
IF YES: enter Book | � Page� i and/or Document #� �
i ` /
B. Does the site contain a brook, body of water nrwetlands? NO _ 0JNTKNOY 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needstobenbtained �-
� Obtained �-� Date /saued'
\�/ �~� | '
' . �
C. Do any signs exist on the property? Y[S �-� NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ���-\ NO �~���
/
IF YES, describe size, type and location: | |
E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orioi!part ofa common plan
that will disturb over 1 acre? YES ND
|F YES,then a Northampton Storm Water Management Permit from the DPVViorequired.
Department use only
City of Northampton of Permit:
Building Department �Curb Cut/Drive-way Permit
WAY It 9 2014 212 Main Street 'Sewer/Septic Availabilit
__j
FaTInspections Room 100 'Water[Well Availabilit.
P in -� - I
�c AA,'1060 rthampton, MA 01060 Two Sets of Structural Plans
Elf. tric jumbing
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
5 C--'.'-� <-�'l (X'j-r— Map Lot Unit
Vo CX— I A&k Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A VICL 15' C-Ioj�-e k� C�,Je- Roccoc r M A o1c)(.'?—
Name(Prin4) -3 C nt Mailing Address:
M 1.7, �
attache-A Te'lepho-nd
Signature
2.2 Authorized Agent:
MIA j nn Qut�amr)ton-
Name-(Print) Current Mailing Address:
( q 13) 521- J4 115
Signature felephone'
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building R00fin (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) Check Number d& 77!5-- 1 0:35
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
15 GARFIELD AVE BP-2014-1219
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-058 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-2014-1219
Project# JS-2014-002061
Est. Cost: $3500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 11717.64 Owner: SHERMAN RICHARD K&KATHLEEN T&RANDY R SHERMAN
TRUSTEE
Zoning: URB(100)/ Applicant: RCI ROOFING
AT: 15 GARFIELD AVE
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.•512012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 2 FLAT ROOFS
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 5/20/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner