17C-122 (3) RCI ROOFING
30 HIGH ST
EASTHAMPTON MA 01027 F(EES:TfIMA TE
(413)527 4775
FAX (413)527 8469 Date: OCT 12 2000
Estimate To:
LAURA SIMMONS Estimated By: CHRIS THOMPSON
52 SHEFFIELD LN Start Date:
NORTHAMPTON,MA 01060 Job Location: NORTHAMPTON
�—JobPhone: 586 6140
JOB DESCRIPTION
REMOVE F ISTING SHINGLES.
FURNISH AND T!VqTATT, ICF & WATFR BARRIER ALONG FAVE� ANT) VAT,rFYS-
yo FURNTSH AND IIVSTALL &YR TAMKO SHTNGTF.
ALL ROOFTNG DFRPTS TO BE REMOVED BY RCT ROOFING,
PROVIDE 25 YEAR 14ANUFACTURERS WARRANTY.
SPECIAL ITEMS NEEDED
Additional information pertaining to this Job Estimate
TERMS OF PAYMENT
30%PRIOR TO START Total Estimated �1z,
70%UPON COMPLETION Job Cost $5400.00 f'�300
CONSTRUCTION LICENSE#074334 -�Q1/�' ��:�/A,+y��`
FEDERAL I.D#3418839 Authonz r
REGISTRATION#126235 Sig
natu
INSURED BY BANAS INSURANCE(413)527 0288
DUPLICATE-CLIENT COPY
04�ItAMp�0
Crxt of 'Wart4Iillptoll
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
be I,- s-/c
with a principal place of business/residence at:
Yo f' (cl "4<1 4/e / z�r� ,YC t:r, 0/0'x- (Phone#P/i
(street city/staf e/rip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
ke
(Insurance Company) (Policy Number) (Expiration Daze)
( ) I 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)
S
(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)
(attach aJ&doaal short if ne«sssry to ia�information pertaining to all ooatsad )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homed wom who employ pa=ne to do mat cazn ce�coastrvctioa or repair work on a dvmirmg of
not atone than three units is which the homeow=resides or on the grou»ds appurtenant thereto are not gcoe ally ooandard to be
emptoyera under the worktt oompcnv4m Act(GL152,a 1(5)),application by a homeowner for a Grease or permit may evidrme the
legal status of an employee under the Worker's Compemation Act.
I undex i that a oopy of this siatem mi may lx forwarded to the Deportment of Lxkotrial Aoddea&Offioe of Imauwoe for the
ooverage verification and that failure to scatre coverago under sccuoa 25A of MOIL 152 can lad to the impositroa of criminal penalties
oomisting of a fine of up to$1,500.00 and/or imptisonmar<of up to one year and civil pcn&Wc3 in the form of a Stop Work Order and a
fmo of 5100.00 a day agninst mo.
For i�tmrraar Use only
Permit Number
map{{_____---Lot#
< q Signature of Licensedpermittee
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �i�` le O 3V
License Nu er/0
Address ' Expira on Date(
Signature Telephone
Not Applicable ❑
PP ^
Company Name Registration Number
Address Expiration Date
Telephone 77�
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT'(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...... ❑
r
Y
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
S9CTl0N 5- DES 1P IO OF PR ° O a is
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ jj Decks [ ] Siding( ] Other[ ]
Brief Description of Proposed Work: A'd G, o 1ti ve f'S 5 ,'A 545
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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. Mascheck 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>TOVE OOMPIL ED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR'BUII;DING PERMIT
i, 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.
Signature of Owner Date
I, ✓ as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the p ns and penalties of perjury.
Print Name �?
106
Signature of Owner/Agent Date
N
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 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:
w T
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: �" s rThi + tl `td bvc ,
oTe '4' y wea�isr ,
SECTION 2, PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature cJ
Telephone [— A G /
2.2 Authorized A ent:
fil,A ` Ke 1 sIC
Name_(/Print) Current Mailing Address:
L rte.
Signature Telephone
SECTION'3•:ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Kermit 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) G G Check Number
This Section 1•or Official Use Only
Building'Permit'Number: Date Issued:
Signature:
Building Commissionerlinspector of'Buildings Date
s
52 SHEFFIELD LANE BP-2001-0440
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 17C- 122 CIT`it OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0440
Proiect# JS-2001-0755
Est.Cost: $5600.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 24872.76 Owner: SIMMONS RICHARD&LAURA
Zoning.URB Applicant: RCI ROOFING
AT: 52 SHEFFIELD LANE
Applicant Address: Phone: Insurance:
30 HIGH ST (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:10130100 0:00:00
TO PERFORM THE FOLLOWINGWORK.STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/30/00 0:00:00 1442 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo