17A-061 Z*-ft�
RC.1. Roofing Date
6 Line St.
Estimate
Southampton,Ma. 01073 10/30/2014
Phone(413)527-4775
Fax(413)527-8469
Name/Address Job Location
Jo Ellen Mackenzie 213 Bridge Rd.
213 Bridge Rd. Florence, MA 01062
Florence, MA 01062 (413) 320-3690
Terms Rep
Estimate valid for 30 days Chris
Description Total
Remove existing roofs. 11,100.00
Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step
flashings.
Furnish&install CertainTeed Winterguard ice&water barrier along eaves and valleys.
Furnish and install synthetic underlayment over existing deck.
Furnish and install Lifetime CertainTeed Landmark 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.
Lifetime CertainTeed material warranty included.
All related permits will be obtained by R.C.I. Roofing.
Add: $2.50 per sq. ft. for wood decking replacement if needed.
Add: $1,200.00 for.032 seamless Gutters
Add: $1,200 for Pro shingles
Spring price: $10,600.00
A Certainteed Surestart plus warranty will be included with a fee of$400.00 absorbed by RCI
Roofing if signed within 7 days. This extended warranty means that 25 years of the Lifetime
warranty is covered for labor and materials. The remaining years of the Certainteed warranty
would be covered for material only.
Customer is responsible for securing interior items and any attic debris from roof removal.
Total $11,100.00
TERMS OF PAYMENT
5%Deposit t
Balance upon completion Customer Signature Wd
i'✓ ' LC°G� �
Registration# 126235
Construction License#074334
Date
Insured by Banas&Fickert Ins. j
(413)527-2700
The Commonwealth of Massachusetts
Department of IndustrialAecidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
w»rw,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrleians/Plumbers
,ppheant Information Please Print Le ibl
7aMe (Business/Organization/Individual): (� L, dp�� r1g U-P —
�ddress: —(.
Q)-v3 ' Phone #: (x(1.3)
re you an employer? Clteck the-appropriate box: Type of project (required):.
�- I am a employer with 2 U 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. # 7, ❑ 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.❑ 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.❑ Other
comp, insurance required,] `
�y applicant that checks box fl l 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
ntractots 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 provlding workers'compensation insurance for my employees. Below is the policy and job site
'ormation.
urance Company Name:
Expiration Date: 10 • 5 . J !4
Site Address: al,25 F��,AA t- �0 City/State/Zip;(Aor'e_ncf—, M A
tach a copy of the workers' compensation 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 penalties 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
vestigatlons 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 correct.
gnature: �'� Date:
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 Supervisor: Not Applicable E3 j�,
Name of Lccense Holder: aY� ,(�,�� / / q,7 3'1
License Number
Address 4 Expiration Date
041?� 521- T7175
Signature Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
Company Name Registration Number
Aoarea� Expiration Date
DltL a 0]'1 i 8,73____.jeIephon6J3�-15.2r -
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"homeowners"was extended to include Owner-occupied Dwelling-s-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 hom vner.
Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that be/she-stlalill 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 ixmn(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,Clty of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature �t,.boc!A ___
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ff— Roofing
Or Doors 71 Fri
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [Cj Siding [C]) Other[ED)
Brief Description of Proposed t
Work: � 1
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
41 'A' as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this"building permit application,
— ;At aehPC1 I - (n _I4
Signature of Owner Date
i , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a&lication 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 Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Oppn Space Footage %
(Lot area minus bldg&paved
4 of Parking Spaces
A. Has o Special Permit/Variance/FincUng ever been issued for/on the site? _
/~�
�_�
NO �_� DON'T KNOY/ �_/ YES
|F YES, date issued:| /
IF YES: Was the permit recorded at the Registry ofDeeds?
��
�� �� E
NO �� DON'T KNOW YS
IF YES: enter Book ! i Page! i and/or Document �
. . . /
�� �_���
B. Does the site contain a brook, body of water orwetionds7 NO v�/ DONT KNKNOW �_� YES
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needs tnbeobtained |osund'
�~� Obtained �^« Date \ /
�-� ' {
C. Do any signs exist on the pm /,~�perty/ YES �.� NO
IF YES, describe size' type and (ocation: } |
D. Are there any proposed changes to or additions of signs intended for the property ? YES ~ NO
0
IF YES, describe size, type and location: | �
E. Will the construction activity disturb((clearing, nn. orfiUing)over 1 o�eoriohpo�nfa common plan
�a|v�Udi�urbover 1 acre? YES K \ NO
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
Department use only
1! CI ry Northampton Status of Permit:
Bdildi6g Department Curb Cut/Driveway Permit
212 Main Street 'Sewer/Septic Availability _
Room 100 Water/Well Availab111ty
Northampton, MA 01060 Two Sets of,Structural Plans
—'' ph`gne 41,3-5,8 240 Fax 413-587-1272 ;Plot/Site Plans
_.� O:ther Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
1 r� ��� �� Map Lot Unit)
Zone Overlay District _
Elm St.District CB District _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: pp
o C�` rl L��h7� T 7i' Ors or �c� ��aCYnC ./AA O1oc e-
Name(Print) Current Mailin dress:
1Lf;1 ' .) --300
-atta clip-d Telephon
Signature
2.2 Authorized Agent:
e. 01.T., L Ulf=-Siz soulb Mo Name(Print) Current Mailing Address: 0101 ,
( �13) 5 27- J4 175
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building n b (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) 0 , 00 Check Number � 5
This Section For Official Use Only
Date
Building Permit Number: Issued: _
Signature:
Building Commissioner/Inspector of Buildings Date
213 BRIDGE RD BP-2015-0551
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-061 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-2015-0551
Project# JS-2015-001055
Est.Cost: $11100.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(ss . ft.): 12153.24 Owner: MACKENZIE JO ELLEN
Zoning.URB(100)/ Applicant: RCI ROOFING
AT. 213 BRIDGE RD
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.11/13/2014 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 11/13/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner