23D-124 (9) WE` TF'F.L-i i7i-i NGT IL :413562:8007- OC7
1 '02 9 3 3 11 o 0 C1 I F, G 2
R.C.1 ROOFING
40 MAINE AVE,
P.O. BOX 309
EASTHAMPTON, MA 01027-0309 C=ES T�
PHONE (413)527. 4775
FAX (413)527-5469
D*W: OCTOBER 3, 2002
Estimme
STEVE FLYNN
116 FEDERAL ST.
FLORENCE, NA. 01062
__ Jnb Phorto: 4i3 505-0392 W-564-2206
JOB DESCRIMION
U AIC4 1/;? 61) QVRT &XZg1'ZAU QECK.W..
1.
44,4 A&LAMM) 1�&IMIZS VA T y R C,T. ROOP-11
SPECIAL ITEMS NFED
FLAT SECTION WILL BE KPCHAOTCALLY FASUIVED RUBBIA.
AdIth.ovOnfourmllon m4riUi to fifs Job 6stimes
Total W(rWed
30%PNOR W 61ART
70%VY0NWMPLViUN -lob Cost-Anlw
MOISIM71an 8 120225
FED,IDN 04:3418839 Authorized
=45 RUCTION LIUNSEf 074334 SAJ711stu
MAW OY MCI WORTHOLAPLANTE WS.(410)5274407
DVPLICATr--r CLIENT COPY
+ O��ttAMP�O
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
(lioensec/Permittee>
with a principal place of business/residence at:
140 C LV E- F— 010 hone#) �1/3 -,,Z7- '77
(atrtWcity/9a1d2iP)
do hereby certify, under the pains and penalties of perjury, that:
Wl'*am an employer providing the following worker's compensation coverage for my
employees wolfing on this job:
a e WC's-31s- '�11 Z9•o1
Company) (Polity Number) (Expiration Dale)
( ) 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 Comparry/Po(icy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attac}i additi—al zycd if noceaary to iochWe idbraution pertaining to all ooatrn )
( ) 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 wbilo homeowners who employ pcmm to do m,intca=ccS con=uc6on or repair work oa a dwelling of
not more thin throe unite in uitieh the hoamwaec raids cc oo the vwn h appurtenant tbacto arc oot wally oomidcmd to be
employ—under the wockAes oompeas4ca Act(GL152.ss 1(5))�application by a homeowwr for a Game or permit may evidcaoc the
legal ctan,s of an employer under the wocle ova Com pemaiioa Ad.
I und--d that a Dopy of this ehtcm taay be forwwd*d to the Departaioos of T-,h, ial Aacidm&OIBoo of lawranoe forth*
coverage verificeioo and that failtme to aoauc aoverago under section 25A of MGL 152 tea kid to this'inVositioa of-kab l peaaltiea
ooasistiug of a f oc of up to 51,500.00 and(or iztspeisonme�of tip to om year and civil pcmWe,is the form of a stop W otit Order and a
find of 6100.00 a day agniast mc.
For&Vrhr=W uao only
permit Number
Map# Lot
Signahtre of Licen,-Ipernnitt, _—
R 1 Licensed Construction Supervisor:- �.` Not Applic(a�ble ❑
Name of License Holder: ^ S� 01 ` 33 —`
` license Number
Address Expiration Date
5711 T7
Signature P, Telephone
92110,12%MIMM! Not Applicable ❑
�z ) 2, 35
Company Name Registration Number
_.� - 11.3 - ay
'Address` l Expiration Date
"1 d Jll ii'1 G1�1�. E t�Y1 Telephone
w .. h 'i4 4• 1� ... � x r Wit,
flVit"'A F! I -NT10 1 p E FF
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...... ❑
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 Sunervisor 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`Hdvised 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
fi
'N
New House O Addition O Replacement Windows Alteration(s)O Roofing
Or Doors O
Accessory Bldg. O Demolition0 New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: rac"17 5, :� �` /r�'°'S y'�'�✓ � � 3�' ,L
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet 0
fiarM, , 1
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
S,EGII YXIiE[V
E M IT.- N*
as Owner of the subject property
hereby authorize104r ������`c. 00C"',t to act on
my behalf, in all matters relative to work authorized by:this building,permit application.
Signature of Owner Date
I, 6 i� C 'C'T Wv as Gwner/Authorized Agent
hereby declare that the statements and information on the foregoing ap tion are true and accurate, to the-best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
M V Z QN 0 0 t
Print Name
w•�
Signature of GyAger/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN-BE
.:_DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning b
This column to be filled in by _- •_.
Building Deg}4trnent,
Lot Sin
Frontage
Setbacks . EMnA
t L• R L: R
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume do 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 Conservatioll.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:
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, RENOVA�E OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTi0Nr1 .slE !
1.1 Property Address:, ` ea a co t
cY
��6X EXIC_ti
SECTION12- PROP,ERT'�QYi►tN RS jlP/AUTHO�(ZED'AGENT
2.1 Owner of Record:
, -
Name(Print) Current Mailing Address
Telephone
Signature .
2.2 Authorized Agent:
Name(Print) Currerit Mailing Address:
q13 21— q 1'"l
Signature Tetephone
SECTION 11 ESTI ATED,CONSTRUCTION CASTS
Item Estimated Cost(Dollars)to be OffiCial Use'Only
completed by ermit appl icant
1. Building (a) Building`Permlt:F4ee '
2. Electrical (b) Estimated Total Gust of
Construction.frorn; 6:
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) t? Check Number
`
his Section For-Official Use,O.nl
Building Permit Number Date Issued;
Signature .;
8u11d� g;Gg�misst�ner(nRtor of B,utldings, ,: DA#e
BP-2003.0635
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003.0635
Project# JS-2003-1044
Est. Cost: $13800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sa. ft.): 20952.36 Owner: FLYNN STEVEN M&SUZANNE
Zoning URB Applicant: RCI ROOFING
AT. 176 FEDERAL ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:1121103 0:00:00
TO PERFORM THE FOLLOWING WORK:ST R I P, PLY & 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/21/03 0:00:00 665 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo